The Burnia: Laparoscopic Sutureless Inguinal Hernia Repair in Girls

[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.

Approach to concurrent inguinal hernias during laparoscopic appendectomy for early appendicitis

PURPOSE

Concurrent inguinal hernia can be a challenge for a pediatric surgeon during a laparoscopic appendectomy in children. We aimed to present our approach to inguinal hernias seen during laparoscopic appendectomy.

METHODS

In our pediatric surgery clinic between July 2019 and December 2022, the records of patients aged 0-18 who underwent laparoscopic appendectomy were retrospectively investigated. The clinical findings, surgical procedure, and results of intervened inguinal hernia cases during laparoscopic appendectomy were evaluated.

RESULTS

Between the study dates, 293 laparoscopic appendectomies were performed in our clinic. Patent processus vaginalis was observed in 5 (1.7%) cases. Laparoscopic hernia repair was performed with the Burnia technique in 2 girls. In one case, the omentum was herniated and adhered to the hernia sac seen during laparoscopy. In another case, swelling in the groin occurred during the introduction of air into the abdomen at the beginning of the operation. Patent processus vaginalis seen in 3 asymptomatic cases was not intervened. There were no postoperative complications or recurrences in the two patients who underwent hernia repair.

CONCLUSION

Hernia repair with the Burnia technique might be safely performed in symptomatic inguinal hernia cases seen during laparoscopic appendectomy for early appendicitis.

Medium-Term Outcomes of the Godoy Burnia Repair: Durability of a Sutureless Laparoscopic Inguinal Hernia Repair in Girls

Background: Several methods to repair pediatric inguinal hernias utilizing a minimally invasive technique have been developed over the decades. These methods often involve passage of suture through the peritoneum at the level of the inguinal ring. We previously described the Godoy Burnia, a laparoscopic, sutureless, cautery-only inguinal hernia repair (IHR), and this follow-up study provides longer term data for this emerging surgical technique. Methods: After institutional review board approval, a single-centered retrospective review was performed of female pediatric patients with Godoy Burnia repair from 2014 to 2021. Demographics, operative details, and outcomes were reviewed. Technique: Through a single umbilical incision, a 3 mm port and camera and 3 mm Maryland dissector are placed into the abdomen. The Maryland dissector grasps the hernia sac, everts it, and brings it into the abdomen. Electrocautery is applied to allow scarring and closure of the inguinal ring. Results: Sixty-nine hernia repairs were performed on 44 patients with ages 5 days to 16 years (average 3.9 years) and weighing 2-70 kg (average 16 kg). Average follow-up was 52.8 months, and average operative times were 14/16 minutes for unilateral/bilateral repair, respectively. Twenty-two percent of hernias were found at time of another surgery and repaired. One recurrence (1.45%) in a 16-year-old patient, and 2 patients with other short-term complications. Conclusions: Godoy Burnia, a single-incision, sutureless, laparoscopic IHR in girls, is an acceptable alternative surgical technique with a low complication and recurrence rate. The longer follow-up in this study demonstrates the durability of the repair in most age groups, and decreased operative times suggest a favorable learning curve.

Laparoscopic Sac Excision as a Definitive Technique for Inguinal Hernia Management in Pediatric Females: A Prospective Study

INTRODUCTION

The utilization of laparoscopic techniques in the management of inguinal hernias among pediatric patients has seen a rising trend. We aimed to assess the efficacy of laparoscopic excision of the hernial sac as a suitable approach for managing inguinal hernias specifically in female patients and conducted a prospective study to investigate this hypothesis.

METHODS

Over a comprehensive four-year period, a total of 99 hernias in 69 female patients were surgically addressed using laparoscopic methods. The surgical procedure primarily involved the laparoscopic inversion and excision of the hernial sac without subsequent distal suturing.

RESULTS

During the initial phase of the study, two cases encountered recurrences within 48 hours post-operation, potentially attributed to incomplete excision. However, in the subsequent period, no further recurrences were recorded.

CONCLUSION

Our study findings support the contention that laparoscopic excision of the sac, without adjunctive closure of the peritoneum, suffices as an effective approach for managing inguinal hernias in female pediatric patients.

Introduction of pediatric laparoscopic inguinal hernia repair in Guatemala

PURPOSE

Introducing new surgical techniques in a developing country can be challenging. Inguinal hernias in children are a common surgical problem, and open repair is the standard surgical approach. Laparoscopic repair has gained popularity in developed countries because of similar results. This study aimed to determine the outcomes following the introduction of laparoscopic repairs in Guatemala.

METHODS

This retrospective analysis of prospectively collected data from all patients under 18 years who underwent laparoscopic repair at Corpus Christi Hospital in Patzun, Guatemala, from September 5th to September 8th, 2022.

RESULTS

A total of 14 patients were included in the study. A board-certified pediatric surgeon and a Guatemalan physician performed all cases. The mean patient age was 7.6 years; 7 boys and 7 girls. All patients were interviewed at 7 days, 30 days, and 6 months. There were no postoperative infections, pain requiring re-evaluation, gonadal atrophy, or hernia recurrence.

CONCLUSION

Under controlled circumstances with limited but proper equipment and disposables, laparoscopic inguinal hernia repairs can be introduced and performed in a developing country with a risk complication profile comparable to that in developed countries. This study provides promising evidence of laparoscopic repair feasibility and safety where surgical resources are limited.

Paediatric laparoscopic inguinal hernia repair: Level of disconnection of peritoneal cuff - An observational study

Introduction

Inguinal hernia is a common surgical condition in children. Conventionally, the open approach for inguinal hernia repair has been considered the gold standard. However, in the past two decades, laparoscopic inguinal hernia repair has gained popularity among paediatric surgeons as an alternative to the open approach. Apart from good cosmesis and shorter stay at hospital, laparoscopy offers clear-cut advantages of visualising contralateral site and simultaneous repair if it is patent. Many techniques for laparoscopic inguinal hernia repair have been proposed. In this retrospective observational study, we are comparing outcomes between proximal and distal disconnection of hernia sac.

Materials and Methods

Ninety-five patients with inguinal hernia were studied in two groups. Group A included 50 patients in which hernia sac was disconnected from the peritoneal cuff proximal to deep inguinal ring (DIR). Group B included 45 patients in which hernia sac was disconnected distal to DIR. Various sociodemographic parameters and intraoperative findings were compared. Outcomes were analysed in terms of post-operative pain, duration of stay at the hospital and recurrences.

Results

In group A, there were 46 males and four females with mean age of 4.01 years with standard deviation (SD) of 2.96. Group B included 37 males and eight females with mean age of 5.09 years with SD of 3.56. Excess post-operative pain was observed in 33 patients in Group A with proximal disconnection of hernia sac whereas it was seen in only three patients in Group B with distal disconnection of sac. The P was 0.001 which was highly significant. The duration of stay in the hospital was more in Group A (2.36 ± 1.22 days) as compared to Group B (1.8 ± 0.66 days) with a P of 0.0076 which was significant. Hernia recurrence was seen in four out of 50 patients in Group A (8%) as compared to no recurrence in Group B. However, the difference was not significant.

Conclusion

The disconnection of hernia sac distal to DIR is associated with less post-operative pain and shorter duration of hospital stay. There is less recurrence seen in distal disconnection of hernia sac as compared to proximal disconnection; however, to achieve the level of significance, a large cohort study is required.

Reduction of recurrence by peritoneal thermal injury in laparoscopic percutaneous extraperitoneal closure of internal ring for inguinal hernia in children

PURPOSE

To evaluate the impact of peritoneal thermal injury (PTI) in the reduction of recurrence incidence in laparoscopic percutaneous extra-peritoneal closure of internal ring (LPEC) for pediatric inguinal hernia (PIH) in children.

METHODS

Medical records of patients undergoing LPEC for PIH at our center were reviewed and divided into 2 groups: Group A (period from June 2017 to December 2017)-without PTI and Group B (period from January 2018 to December 2018) with PTI. The surgical technique and the type of suture used for LPEC were the same for both groups. The outcomes of the two groups were analyzed and compared.

RESULTS

277 patients with 283 IHs in group A were compared to 376 patients with 389 IHs in group B. There were no significant differences between the two groups in terms of age, gender, uni- or bilateral hernia. At a median follow-up period of 48 months, there was no hydrocele, suture granuloma, testicular atrophy, or iatrogenic cryptorchidism in both groups. The recurrence rate in group A was 6.4%, significantly higher than 1.8% in group B (p = 0.002).

CONCLUSIONS

Our study showed that PTI in LPEC for PIH is safe and associated with a significant reduction of recurrence incidence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Percutaneous Internal Ring Suturing (PIRS) – The Benefits of Laparoscopic Inguinal Hernia Repair

Introduction

The laparoscopic inguinal hernia repair in children using the PIRS technique is a well-established method. However, there are still opinions that this method does not bring more benefits than open surgery.

Purpose

The study aims to demonstrate the benefits of laparoscopic technique over conventional, open techniques.

Patients and Methods

We conducted a retrospective study that included children aged 0–18 treated using the PIRS technique in 2008–2016. The control group consisted of patients treated with the traditional, open method of inguinal hernia repair. A total of 276 children were qualified for laparoscopic surgery, and there were 274 patients in the control group. A full laparoscopic procedure was performed on 247 patients. Assessment of the pathology of the internal inguinal ring was done in all patients during the laparoscopic procedure. Intraoperatively 79 children had bilateral inguinal hernia diagnosed, 133 right-sided inguinal herniae, and 57 left-sided inguinal herniae. The occurrence of hernia was not confirmed in 7 children, whereas 53 patients had open contralateral patent processus vaginalis. In a case of contralateral patent processus vaginalis, the repair was performed using the PIRS method.

Results

The recurrence of the inguinal hernia was observed in 10 children in the laparoscopic group and in 5 cases in control group. The duration of the procedure was noted and compared to open inguinal hernia repair. There was a statistically shorter duration of the laparoscopic method. In the control group, there were 16 patients with a metachronous contralateral inguinal hernia.

Conclusion

The laparoscopic inguinal hernia repair was associated with a better assessment of hernia pathology, shorter operative time, and lower risk of contralateral hernia repair.

A Clinical Study of Minilaparoscopy in the Treatment of Cryptorchidism with an Ipsilateral Inguinal Hernia

Introduction: The aim of this study was to investigate the safety and efficacy of performing minilaparoscopy compared with standard laparoscopy in the treatment of cryptorchidism with an ipsilateral inguinal hernia. Materials and Methods: In total, 46 patients with cryptorchidism and an ipsilateral inguinal hernia were admitted to the Urology and Hernia and Abdominal Wall Surgery Departments of Beijing Chaoyang Hospital between October 2009 and July 2019. They were assigned to two groups: Group M and Group S. In Group M, 24 patients underwent herniorrhaphy and orchiopexy using minilaparoscopy, and in Group S, 22 patients underwent herniorrhaphy and orchiopexy using standard laparoscopy. Surgeons chose the procedure at random, and the patients were blinded to the selected procedure. Results: Postoperative painkiller demand (P = .043) and first postoperative day Numerical Rating Scale scores (P = .032) were lower in Group M than Group S, and the average hospital stay was shorter (P = .041) in Group M. Furthermore, 21 of the 24 procedures in Group M were successful, 3 procedures of Group M were converted from mini- to standard laparoscopy, and all 22 procedures in Group S were successful. The Observer Scar Assessment Scale questionnaire results of Group M were significantly higher than for patients in Group S (P = .038). Conclusion: Our findings suggest that treatment of cryptorchidism with ipsilateral inguinal hernia using minilaparoscopy is as safe and effective as standard laparoscopy.

Single-site laparoscopic burnia for inguinal hernias in girls: comparison with open repair

BACKGROUND

Burnia is a suturless repair for inguinal hernias in girls. It is performed under laparoscopy by grabbing the sac, inverting it into the peritoneal cavity, and cauterizing. The aim of this study is to report our experience with single-site laparoscopic burnia (BURNIA) and compare them with open repair (OPEN).

METHODS

With IRB approval, pediatric female patients younger than 18 years of age who underwent inguinal hernia repair between January 2015 and December 2017 were enrolled. Medical records were retrospectively reviewed. The patients were divided into two groups, BURNIA and OPEN.

RESULTS

198 patients were included. In BURNIA, 49 patients underwent bilateral repairs, and 50 patients underwent 51 unilateral repairs (one patient had metachronous contralateral hernia). In OPEN, 27 patients underwent bilateral repairs, and 72 patients underwent 77 unilateral repairs (five patients had metachronous contralateral hernias). The mean age of BURNIA was similar to OPEN for bilateral repairs (49.1 ± 36.6 vs. 43.7 ± 26.4 months, p = 0.46), but significantly older for unilateral repairs (54.6 ± 29.8 vs. 29.0 ± 31.4, p < 0.01). The mean operation time of BUNIA was similar to OPEN for bilateral repairs (24.2 ± 7.6 vs. 22.4 ± 8.6 min, p = 0.35), but significantly longer for unilateral repairs (19.2 ± 7.0 vs, 13.6 ± 8.8 min, p < 0.01). The mean follow-up duration of BURNIA was significantly shorter than OPEN for bilateral and unilateral repairs, respectively (32.5 ± 8.8 vs. 45.4 ± 4.8 months, p < 0.01) (30.2 ± 8.8 vs. 39.1 ± 9.6 months, p < 0.01). No conversion was required in BURNIA. There were no complications and no recurrence in all patients.

CONCLUSIONS

Single-site laparoscopic burnia is technically feasible, and as safe and effective as open inguinal hernia repair.

Single-port laparoscopic percutaneous closure of the internal ring for scarless repair of inguinal hernias in girls

Purpose: The purpose of this study was to summarize the clinical experience with laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural needle for inguinal hernias in girls.Material and methods: A total of 462 girls with inguinal hernias participated in this study from January 2013 to June 2019. Laparoscopic percutaneous extraperitoneal closure of the internal ring via an epidural needle was used to treat these patients.Results: All 462 girls with an inguinal hernia successfully underwent laparoscopic surgery. The operative times for unilateral and bilateral inguinal hernias were 15 (11-25) minutes and 23 (18-33) minutes, respectively. All patients were discharged 1-2 days after the operations. During the hospitalization and follow-up periods, none of the following complications were observed: hernia recurrence, umbilical hernia, abdominal wall vascular injury, intestinal injury or bladder injury. However, there were six patients with complications: two cases of poor healing of the umbilical incision, three cases of suture granulomas and one case of groin traction pain and discomfort.Conclusion: Laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural needle is a safe and feasible method for the treatment of inguinal hernias in girls. This method has the advantages of limited trauma, no scarring and a good cosmetic effect.

The Ideal Candidate for Subcutaneous Endoscopically Assisted Ligation (SEAL) of the Internal Ring for Pediatric Inguinal Hernia Repair

Subcutaneous endoscopically assisted ligation (SEAL) technique is an effective and minimally invasive approach for indirect inguinal hernia repair in children. Not all patients are candidates for SEAL because of technical limitations. We hypothesized that preoperatively assessed patient-level factors may predict technical feasibility of SEAL repair. We performed a retrospective review of all patients who underwent indirect inguinal hernia repair between June 2012 and December 2014. All patients younger than two years and any patient older than two years who had a concomitant umbilical hernia were considered candidates for diagnostic laparoscopy with SEAL repair. We compared patients who had SEAL repair with those who had diagnostic laparoscopy with conversion to open repair. Univariate statistics was performed using the chi-squared and Student's t test. One hundred forty-one patients underwent diagnostic laparoscopy with intent to perform a SEAL repair. Seventeen patients were lost to follow-up. Of the remaining 124 patients, 66 had SEAL repairs, 35 had open repairs, and 23 had a SEAL repair with contralateral open repair. Patient age, BMI, gender, history of prematurity, and history of incarcerated hernia were similar between the SEAL and open groups. Sixty-two per cent of hernias were able to be repaired with SEAL technique. Hernia recurrence was seen in 3 of 123 total SEAL repairs and in 1 of 74 open repairs. The recurrence rate for SEAL repairs (2.4%) was not significantly different from the recurrence rate for open repairs (1.4%). No preoperative patient-level factors predicted technical inability to perform a successful SEAL repair. In this series, the recurrence risk of SEAL compared with open repair was low and not statistically significant. For practitioners with minimally invasive experience, SEAL should be considered a safe and successful option for inguinal hernia repair in pediatric patients undergoing routine diagnostic laparoscopy.

Laparoscopic suture-less herniotomy using tissue-sealing device for paediatric hydrocele

Introduction:

Laparoscopic herniotomy (LH) for hydrocele is an accepted procedure and provides advantages of contralateral diagnosis and repair with the same incisions. The suturing of patent processus vaginalis is associated with various complications. We describe suture-less herniotomy using tissue-sealing device for LH of hydrocele in children.

Materials and Methods:

The study was carried out on a prospective group of 21 children presenting with hydrocele after 1 year age over a period of 2 years. All infants with hydrocele and complicated hydroceles were excluded. The technique involved peritoneal incision and sealing of hydrocele sac with tissue-sealing device.

Results:

A total of 21 patients (28 hydroceles) were operated. The age ranged from 1 year to 14 years (mean age, 4 years). Ten right, 4 left and 7 bilateral hydroceles (2 diagnosed on laparoscopy) were operated. Operative time ranged from 15 to 32 min, with a mean time of 18 min. All patients were discharged after a hospital stay of 12 h. No recurrences were observed during the follow-up period. One patient had persistent hydrocele for 4 months which resolved spontaneously.

Conclusion:

The laparoscopic suture-less herniotomy for paediatric hydrocele is a safe, secure and easy procedure which can reduce suture and suturing-related complications following LH in hydroceles.

Evidence supporting laparoscopic hernia repair in children

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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