Pediatric Laparoscopic Inguinal Hernia Repair: A Review of the Current Evidence

[Spectrum of Minimally Invasive Surgical Techniques for the Managment of Inguinal Hernias in Infants and Children]

One of the most common surgical procedures in infants and children is the repair of an indirect inguinal hernia. This can be carried out by open technique or using minimally invasive surgery (MIS). Since 1998, numerous different MIS techniques have been described. Scientifically proven advantages include a shorter operation time for bilateral hernias, along with a lower risk of metachronal, contralateral hernia. Nevertheless, the proportion of inguinal hernias treated using MIS in children in this country is relatively low, at around 8% of all operations. The aim of this synopsis is to describe the different MIS techniques for inguinal hernia repair in children, including their respective advantages and disadvantages.This video compilation shows the spectrum of different techniques for laparoscopic inguinal hernia repair in children. It includes the intracorporeal suturing technique, the incision of the peritoneum, extracorporeal percutaneous techniques, and the cauterisation of the open peritoneal vaginal process in girls.Although minimally invasive inguinal hernia repair in children is technically and scientifically established, it is not yet being widely used. This video manuscript provides an overview of the various techniques, thus facilitating clinical application.

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

INTRODUCTION

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sutureless versus purse string with complete sac dissection in laparoscopic inguinal hernia repair in children: a randomized clinical trial

Introduction

Pediatric inguinal hernia is a common surgical condition with a cumulative incidence of 4.2%. Minimal invasive surgery is playing a growing role in the treatment of this condition. We compared the outcomes of laparoscopic sutureless herniotomy and purse string with sac dissection repair with regards to complications and operative time.

Methods

One hundred fifty-two patients were operated on in two centers with two different techniques: sac dissection and purse-string suture, and sutureless repair. Operative time and recurrence were the main outcomes for comparison.

Results

Sutureless repair has a shorter operative time (29 ± 10 min) compared to purse string repair (38 ± 13 min). The recurrence rate showed no statistical significance difference. However, the recurrence rate of sutureless repair was three times higher than that of purse string repair, and all recurrences were in large defects of 10–15 mm.

Conclusions

Sutureless repair is safe for defects up to 10 mm with excellent operative time. However, it had an unfavorable outcome in larger defects.

Pediatric Minimally Invasive Surgery-A Bibliometric Study on 30 Years of Research Activity

Background: Pediatric minimally invasive surgery (MIS) is a standard technique worldwide. We aimed to analyze the research activity in this field. Methods: Articles on pediatric MIS (1991−2020) were analyzed from the Web of Science™ for the total number of publications, citations, journals, and impact factors (IF). Of these, the 50 most cited publications were evaluated in detail and classified according to the level of evidence (i.e., study design) and topic (i.e., surgical procedure). Results: In total, 4464 publications and 53,111 citations from 684 journals on pediatric MIS were identified. The 50 most cited papers were published from 32 institutions in the USA/Canada (n = 28), Europe (n = 19), and Asia (n = 3) in 12 journals. Four authors (USA/Europe) contributed to 26% of the 50 most cited papers as first/senior author. Hot topics were laparoscopic pyeloplasty (n = 9), inguinal hernia repair (n = 7), appendectomy, and pyloromyotomy (n = 4 each). The majority of publications were retrospective studies (n = 33) and case reports (n = 6) (IF 5.2 ± 3.2; impact index 16.5 ± 6.4; citations 125 ± 39.4). They were cited as often as articles with high evidence levels (meta-analyses, n = 2; randomized controlled trials, n = 7; prospective studies, n = 2) (IF 12.9 ± 22.5; impact index 14.0 ± 6.5; citations 125 ± 34.7; p > 0.05). Conclusions: Publications on laparoscopic pyeloplasty, inguinal hernia repair, appendectomy, and pyloromyotomy are cited most often in pediatric MIS. However, the relevant number of studies with strong evidence for the advantages of MIS in pediatric surgery is missing.

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.

Is the open approach superior to the laparoscopic hernia repair in children? A retrospective comparative study

Background

For many years now, inguinal hernia repair in children has been done either by the open approach or laparoscopically with laparoscopy having the edge in terms of cosmesis and postoperative pain. However, recent studies have called for a return of the open approach as it had a comparable result to laparoscopy with lesser cost. This study aims to compare the outcomes of the two approaches at our institution.

Methods

This is a retrospective analysis of the prospectively collected data of all patients aged between 6 months and 13 years who underwent open or laparoscopic inguinal hernia repair in the period between January 2017 and July 2019 at our institution.

Results

155 patients were included in the study. 100 (64.5%) underwent open inguinal repair while 55 (35.5%) were done laparoscopically. There was no significant difference in the postoperative complications between the open and laparoscopic groups (P = 0.66). The overall mean operative time for the laparoscopic group and the open group is (45.7 ± 15.2, 45.5 ± 15.4 min, P = 0.83) respectively. However, a subgroup analysis showed a statistical difference in the operative time in bilateral hernias favoring the laparoscopic approach, (44 ± 13.2, 63.2 ± 26.4 min respectively, P = 0.049). Laparoscopy was also associated with shorter times to full recovery compared to the open group (4.7 days, 7.5 days, P = 0.013). Surprisingly, there was no difference in the cosmetic outcome between the two groups which is contrary to the published literature.

Conclusions

Laparoscopic inguinal hernia repair in children is a feasible and reproducible procedure. It permits the evaluation of the contralateral groin without further incisions. In our study, laparoscopy was superior in terms of operative time in bilateral hernias and the time to recovery. Finally, an added benefit to laparoscopy is that it offers more training opportunities for fellows and residents to improve their laparoscopic skills.

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Laparoscopic inguinal hernia repair in children is a feasible and reproducible procedure.

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Laparoscopy was superior in terms of operative time in bilateral hernias and the time to recovery.

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Laparoscopic hernia repair in children offers more training opportunities for fellows and residents to improve their laparoscopic skills.

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.

National Trends and Disparities in the Diffusion of Laparoscopic Surgery for Children in the United States

Background: Laparoscopic surgery has become the standard of care for many surgical treatments. The diffusion of laparoscopy has been investigated for adult patient populations but is still unknown for pediatric populations. This study sought to describe national trends in diffusion of laparoscopic surgery for common pediatric conditions and identify disparities in use of laparoscopic surgery. Study Design: A retrospective analysis of serial cross-sectional data was performed using the Healthcare Cost and Utilization Project's Kids' Inpatient Database from 1997 to 2016. Pediatric patients (ages ≤18) undergoing appendectomy, cholecystectomy, fundoplication, or inguinal hernia repair were identified. The diffusion of laparoscopy for each procedure was measured using the proportion of laparoscopic surgeries over years. Results: National trends demonstrate increases in the use of laparoscopy for children over the past two decades from 13.4% to 88.7% for appendectomy, from 82.6% to 94.9% for cholecystectomy, from 7.4% to 77.4% for fundoplication, and from 1.5% to 23.5% for repair of inguinal hernia (P < .001). Disparities in diffusion of laparoscopy were found from various pediatric populations, and the disparities varied by specific procedures and years. In particular, the proportion of laparoscopic appendectomy in 1997 was 11.3% at urban teaching hospitals and was 13.9% at rural hospitals (P = .01), while the proportions in 2016 increased to 90.8% at urban teaching hospitals versus 71.3% at rural hospitals (P < .001). Conclusions: Laparoscopy has become the standard surgical care for common pediatric surgical conditions. Widening disparities in use of laparoscopic surgery for pediatric populations appear between urban teaching hospitals and rural hospitals.

A single institution experience with Laparoscopic Hernia repair in 791 children

INTRODUCTION

There are many described technique to performing laparoscopic inguinal hernia repair in children. We describe our outcomes using a percutaneous internal ring suturing technique.

METHODS

A retrospective review of patients under 18 years old who underwent repair between January 2014 - March 2019 was performed. A percutaneous internal ring suturing technique, involving hydro-dissection of the peritoneum, percutaneous suture passage, and cauterization of the peritoneum in the sac prior to high ligation, was used. p < 0.05 was considered significant during the analysis.

RESULTS

791 patients were included. The median age at operation was 1.9 years (IQR 0.37, 5.82). The median operative time for a unilateral repair was 21 min (IQR 16, 28), while the median time for a bilateral repair was 30.5 min (IQR 23, 41). In total, 3 patients required conversion to an open procedure (0.4%), 4 (0.6%) experienced post-operative bleeding, 9 (1.2%) developed a wound infection, and iatrogenic ascent of testis occurred in 10 (1.3%) patients. Twenty patients (2.5%) developed a recurrent hernia. All but two were re-repaired laparoscopically.

CONCLUSIONS

The use of percutaneous internal ring suturing for laparoscopic repair of inguinal hernias in the pediatric population is safe and effective with a low rate of complications and recurrence.

Pediatric Surgeons' Adoption of an Innovative Laparoscopic Technique for Inguinal Hernia Repair: A Mixed Methods Study

Purpose: We studied adoption of an innovative laparoscopic technique for pediatric inguinal hernia repair by pediatric surgeons and pediatric urologists following dissemination of evidence for its benefits. Methods: This mixed methods study included children who received inguinal hernia repairs during 2017-2019 and their surgeons. We examined surgeons' adoption and use of the innovative technique and rates of ipsilateral recurrence and metachronous contralateral repair. In-depth interviews with surgeons were used to identify themes regarding attitudes and practices regarding the adoption of surgical innovations. Results: No ipsilateral recurrences were noted among open repairs after 1.5 years of average follow-up, while 1.54% (7/453) of unilateral and 0.50% (3/606 sides) of bilateral innovative surgeries required ipsilateral repair after 1.3 years of average follow-up. Among unilateral cases, metachronous contralateral repairs were performed in 1.63% (8/490) of open and 0.44% (2/453) of innovative surgeries. Surgeon interviews identified approaches to continued learning and change; the role of departmental culture, norms, and resources; and technical issues specific to pediatric surgery and pediatric inguinal hernia repair. Conclusions: Outcomes may have improved over time as a consequence of learning. Differences among surgeons and departments influenced the speed of adoption. Surgeons linked the collegial model used when adopting the new technique to the apprenticeship model used during their training. We propose research into the collegial model to improve translation of evidence-based surgical innovations into practice. Level of Evidence: Level III.

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

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

Modified percutaneous internal ring suturing with peritoneal injury in children: matched comparison to open hernia repair

BACKGROUND

The aim of this study was to elucidate the outcomes of percutaneous internal ring suture (PIRS) technique for inguinal hernia repair augmented with thermal peritoneal injury compared to open inguinal hernia repair (OHR) in a large population of contemporary pediatric patients. Thermal injury with PIRS has been shown to reduce recurrence in animal models and is increasingly being incorporated into clinical practice.

METHODS

Retrospective review of all PIRS procedures and OHR between Jan-2017 to Sept-2018 was performed. Data regarding patient characteristics, characteristics of the hernia, operative details, postoperative complications, and recurrence were collected. Non-parametric tests were used and p < 0.05 was regarded as statistically significant. 1:1 Propensity score matching was performed using "nearest-score" technique. Matching was done based on age, sex, follow-up time, side of hernia, repair of contralateral hernia, and number of additional procedures.

RESULTS

90 modified PIRS patients were matched to 90 OHRs. Patient demographics, hernia characteristics, and follow-up time were similar between the two groups after matching. There were no differences in recurrence rates (1 vs. 3 in OHR and PIRS, respectively, p = 0.6), complication rates (1 vs. 4 in OHR and PIRS, respectively, p = 0.4), and OR time [44.5 vs. 43 min in OHR and PIRS, respectively, p = 0.8]. There were no intraoperative complications for either technique. For OHR, laparoscopic look was performed in 23%. When successful, it revealed a contralateral PPV (patent processus vaginalis-PPV) in 41% of cases (9.4% of all OHR), all of which were repaired. For the PIRS procedures, a contralateral PPV was found in 25.6%, all of which were repaired. In the unmatched population, OHR had a metachronous hernia rate of 1.8%, none of whom had the contralateral PPV repaired at the original procedure.

CONCLUSIONS

PIRS with peritoneal injury has comparable efficacy and good safety compared to OHR. Recurrence and complication rates should further improve with increasing experience. Future studies should elucidate long term outcomes.

Long-term follow-up of pediatric open and laparoscopic inguinal hernia repair

BACKGROUND

Pediatric laparoscopic inguinal hernia repair is not widely accepted.

STUDY DESIGN

Children 0-14 years who underwent inguinal hernia repair during 2010-2016 at Kaiser Permanente Northern California were classified into five groups: (1) open unilateral repair without contralateral exploration; (2) open unilateral repair with contralateral laparoscopic exploration ("open+explore"); (3) open bilateral repair; (4) laparoscopic unilateral repair; and (5) laparoscopic bilateral repair. Outcomes included ipsilateral reoperation, metachronous contralateral repair, incision time, and complications.

RESULTS

The study included 1697 children. Follow-up averaged 3.6 years after open (N = 1156) and 2.6 years after laparoscopic (N = 541) surgery. Metachronous contralateral repair was performed in 3.8% (26/683) of patients with open unilateral surgery without contralateral exploration, 0.7% (2/275) of open+explore patients, and 0.9% (3/336) of laparoscopic unilateral patients (p < 0.01). Ipsilateral repair was performed in 0.8% (10/1156) of open repairs and 0.3% (2/541) of laparoscopic repairs. Chart review confirmed 5 postoperative infections in 1156 patients with open surgery (0.43%) and 6 infections in 541 patients with laparoscopic surgery (1.11%) (p = 0.11).

CONCLUSION

Our study's laparoscopic and open approaches have similar low ipsilateral reoperation rates, incision times, and complications. The use of laparoscopy to visualize the contralateral side resulted in a significantly lower rate of metachronous contralateral repair.

LEVEL OF EVIDENCE

Level III.

Simulation in Pediatric Video Surgery: Training with Simple and Reproducible Exercises Elaborated by Residents

Background: Most residents do not have a defined program for simulation training in video surgery in Brazil. The training takes place for the most part in vivo or in short courses. The goal of this article is to describe and evaluate a set of exercises using low-cost materials, created by the residents themselves, to enable basic skills training in video surgery. Materials and Methods: Seven exercises were elaborated aiming to simulate main maneuvers performed in video surgery. The residents were guided by a written and video description showing the execution of the exercises, performed the exercises, and answered a questionnaire. After 3 weeks of free training, the residents performed the exercises and answered the questionnaire again. Results: Seven residents started the study; however, 6 completed the two steps. Among the participants, 83% received in vivo video surgery training, and only 2 (33%) received some supervised simulation training in minimally invasive surgery before this time. All participants considered the set of seven exercises representative of the actual skills in video surgery. There was no difficulty in acquiring the materials or in assembling them to carry out the training. All the participants had a shorter training time than initially proposed, on average 1 day/week for 20 minutes. Conclusions: A simple set of exercises can be elaborated by the residents themselves and make feasible the simulated training in video surgery even without the availability of sophisticated and expensive materials. The presence of a tutor and the scheduling of exclusive training seem necessary for more satisfactory results.

Current practice patterns for postoperative activity restrictions in children

BACKGROUND

Postoperative activity restrictions are designed to prevent undue stress on a recent repair and minimize the risk of surgical complication, however, there is little evidence to support certain restrictions in clinical practice. For the pediatric population, there is a paucity of formal evaluations of postoperative activity restrictions, and little is known about current practice patterns among pediatric surgeons. This study aimed to describe national practice patterns of pediatric surgeons for postoperative activity recommendations following three common general surgical procedures.

METHODS

A 7-item survey was sent to all American Pediatric Surgical Association (APSA) members regarding surgeon practice of recommended activity restrictions for school attendance, participation in playground or gym, participation in contact sports, and heavy lifting in children following 3 procedures: exploratory laparotomy, laparoscopic appendectomy, and inguinal hernia repair. Information on type and duration of clinical practice was also collected for each surgeon. Descriptive and bivariate analyses were performed.

RESULTS

The survey was completed by 293 pediatric surgeons for a response rate of 28.9%. There was wide national variability in the recommended activity restrictions for children <12 years old among pediatric surgeons. Following laparoscopic appendectomy, 30.7%, 51.9% and 47.8% of surgeons recommends restriction of gym, contact sports, and heavy lifting for 2-3 weeks respectively, but 26.7%, 19.8%, and 22.2% do not recommend any restriction whatsoever of these three activities. Following inguinal hernia repair, 31.7%, 49.1% and 44.4% of surgeons recommend restriction of gym, contact sports, and heavy lifting for 2-3 weeks, but 30.8%, 30.8%, and 29.2% do not recommend any restriction of these three activities. Only 22% of surgeons change their activity restriction recommendations for children ≥12 years old, this decision was not associated with surgeon years in practice or type of practice.

CONCLUSIONS

There is considerable variability in surgeon recommendations for activity restrictions following three general surgery procedures in children. While activity restrictions are rooted in the physiology of wound healing, there is little evidence to support the benefit of these restrictions in clinical practice. In addition, activity restriction may have unintended deleterious effects on a child's psychosocial well-being and quality of life. Further investigation should be pursued to understand the utility of activity restrictions in children and their impact on clinical outcomes and patient quality of life.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level V, expert opinion.

Needlescopic assisted internal ring suturing; a novel application of low-cost home-made instruments for pediatric inguinal hernia repair

BACKGROUND

Congenital inguinal hernia (CIH) is a commonly performed surgical procedure in infants and children. Single port laparoscopic hernia repair using percutaneous internal inguinal ring (IIR) suturing procedure is a widely employed technique for indirect inguinal hernia repair in children. The majority of extracorporeal techniques use extracorporeal knotting and burying the knot subcutaneously. This may result in many drawbacks. The aim of this multicenter study is to introduce a new technique for pediatric inguinal hernia repair using only needles without any laparoscopic instruments.

PATIENTS AND METHODS

This is a multicenter study which was conducted at Pediatric Surgical Departments of Al-Azhar, Mansoura, Alexandria and Tanta Universities during the period from January 2015 to June 2017. 314 patients with CIH underwent Needlescopic Assisted Internal Ring Suturing (NAIRS) after cauterization of the hernia sac at its neck. The main outcome measures were: feasibility, safety of the technique, operative time, recurrence rate, hydrocele and cosmetic results.

RESULTS

A total of 314 patients with CIH were corrected by NAIRS. They were 232 males and 82 females. The mean age was 28.12 ± 1.3 months (range 6-120 months). The mean operative time was 12.6 ± 1.7 min (range 8-15 min) for unilateral cases and 18.6 ± 1.7 min (range 14-20 min) for the bilateral repairs. All cases were completed laparoscopically without major intraoperative complications. No recurrence was detected in this study. No wound complications or umbilical hernias developed. Hydrocele occurred in five males (2.16%), without detection of testicular atrophy or iatrogenic ascent of the testis.

CONCLUSION

This preliminary study showed that NAIRS after cauterization of the neck of the hernia sac in infants and children is safe, feasible, reproducible with excellent cosmetic results.

Inguinal Hernia

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

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.

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.

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.

The laparoscopic approach for repair of indirect inguinal hernias in infants and children

Repair of an indirect inguinal hernia is one of the most common operations performed around the world by pediatric surgeons. Until the last 15 years, most inguinal hernia repairs were performed using an inguinal crease incision and extraperitoneal ligation of the patent processes vaginalis. However, since 2000, the laparoscopic approach has gained popularity and there have been increasing descriptions about various techniques for laparoscopic hernia (LH) repair. At our institution, we have transitioned the majority of inguinal hernia repairs to the laparoscopic approach. In this article, we will describe the technique that is utilized at Children's Mercy Hospital in Kansas City, Missouri (USA) and express our thoughts on the current debate regarding laparoscopic versus open inguinal hernia repair in infants and children.

Pediatric surgery - a changing field: national trends in pediatric surgical practice

BACKGROUND

Over the last decade, our institution has experienced a relative increase in the number of mundane cases, such as appendectomy and incision and drainage of abscess, versus index (complex) cases. We sought to determine if this trend is present at the national level.

METHODS

A retrospective review of surgical case volume at 36 freestanding children's hospitals was performed between January 2004 and December 2013 using the Pediatric Health Information System (PHIS) database. Procedures were classified as "mundane" or "index", and 10 procedures of each type were selected for analysis. Results were reported as a percentage of total cases. Statistical analysis of linear trends was performed with the Mann-Kendall test.

RESULTS

Overall, index procedures had a significant downward trend (p<0.01), whereas mundane procedures had a significant upward trend (p<0.01). Individually, 5 mundane procedures had significant upward trends, and 3 had downward trends. Five index procedures had significant downward trends, and none had an upward trend.

CONCLUSION

The field of pediatric surgery is undergoing change with mundane procedures constituting an increasing proportion of the surgical caseload, while complex procedures are proportionately decreasing. These trends may be useful to inform decisions regarding future pediatric surgery workforce planning.