Inguinal hernia: what we have learned from laparoscopic evaluation of the contralateral side

AI's deep dive into complex pediatric inguinal hernia issues: a challenge to traditional guidelines?

OBJECTIVE

This study utilized ChatGPT, an artificial intelligence program based on large language models, to explore controversial issues in pediatric inguinal hernia surgery and compare its responses with the guidelines of the European Association of Pediatric Surgeons (EUPSA).

METHODS

Six contentious issues raised by EUPSA were submitted to ChatGPT 4.0 for analysis, for which two independent responses were generated for each issue. These generated answers were subsequently compared with systematic reviews and guidelines. To ensure content accuracy and reliability, a content analysis was conducted, and expert evaluations were solicited for validation. Content analysis evaluated the consistency or discrepancy between ChatGPT 4.0's responses and the guidelines. An expert scoring method assess the quality, reliability, and applicability of responses. The TF-IDF model tested the stability and consistency of the two responses.

RESULTS

The responses generated by ChatGPT 4.0 were mostly consistent with the guidelines. However, some differences and contradictions were noted. The average quality score was 3.33, reliability score was 2.75, and applicability score was 3.46 (out of 5). The average similarity between the two responses was 0.72 (out of 1), Content analysis and expert ratings yielded consistent conclusions, enhancing the credibility of our research.

CONCLUSION

ChatGPT can provide valuable responses to clinical questions, but it has limitations and requires further improvement. It is recommended to combine ChatGPT with other reliable data sources to improve clinical practice and decision-making.

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.

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.

Modified 2-port laparoscopic herniorrhaphy with Kirschner wire in children: A retrospective review

BACKGROUND

Pediatric inguinal hernia is one of the most common diseases in children, and laparoscopy is the main surgical method. This study aims to evaluate the efficacy of a new modified 2-port laparoscopic herniorrhaphy with Kirschner wire (TLHK) for inguinal hernia in children.

METHODS

A total of 5304 children with inguinal hernia hospitalized at the Jiangmen Center Hospital from June 2003 to May 2016 were enrolled in this retrospective study. Four thousand one hundred thirty-five children underwent TLHK that comprised the observation group, while 1169 received single incision laparoscopy (SIL) as the control group (CG). A propensity score matched cohort study was conducted between these groups. We included all patients who were diagnosed as inguinal hernia and matched comparators with a proportion of 1:1. The propensity score was calculated using logistic regression with forward stepwise selection in 4 variables. The patients' operative details, intra- and postoperative complications, and postoperative hospital stay were analyzed. The follow-up lasted from 1 month to 2 years.

RESULTS

Among 5304 potential patients, the propensity score identified 270 (135 TLHK cases and 135 comparators) patients. The age, sex, body mass index, and the hernia type and location did not differ between CG and TLHK. TLHK group had a shorter operative time (unilateral: 17.4 ± 3.35 minutes vs 20.7 ± 3.71 minutes; bilateral: 20.4 ± 5.17 minutes vs 25.2 ± 5.43 minutes), less complications (2.10% vs 2.65%), lower recurrence rate (0% vs 4.44%), and similar hospital stay (2.3 ± 1.1 vs 2.1 ± 1.3) as compared with CG. No iliac vessel injury, spermatic cord vessels injury, vas deferens injury, or iatrogenic cryptorchidism occurred in either of the groups.

CONCLUSION

TLHK is a safe and feasible treatment for inguinal hernia in children due to less invasion and less recurrence rate than SIL.

Inguinal hernia repair by Bianchi incision in boys: a retrospective study

OBJECTIVE

Open inguinal hernia repair by Bianchi incision is a potential alternative technique for the treatment of IH. This study aims to retrospectively analyze boys with IH, who underwent open IH repair by Bianchi incision.

METHODS

A total of 3300 boys (1-144 months) with IH from April 2007 to September 2015 were enrolled into this study. An open high scrotal incision (Bianchi incision) to ligate the processus proximal to the internal inguinal ring was performed in patients for IH repair. Then, all patients were followed up after 7 days, 1 month, and 1 year. Operation time, hernia recurrence, hydrocele, testicular atrophy, cosmetic results, and the satisfaction of parents were evaluated.

RESULTS

Among these 3300 boys, 1662 (50.36%) and 1349 (40.88%) boys with IH were operated on the right and left side, respectively, while 289 (8.76%) patients underwent bilateral surgery. The average operation time was 13.0 ± 2.3 min for unilateral cases and 25.2 ± 4.2 min for bilateral cases. Furthermore, among these 3300 boys, 309 boys (9.36%) were lost to follow-up, and the remaining 2991 boys underwent a total of 3245 IH repairs. The complications included 20 recurrences who were repaired with the same technique, one wound rupture, and one acquired undescended testis. No infection, obvious scrotal hematoma, testicular atrophy, and vas deferens injury were found during the follow-up. In most instances, the scars were invisible, obtaining an excellent cosmetic effect.

CONCLUSION

Inguinal hernia repair by Bianchi incision is a safe, easy and effective technique with cosmetic benefits, which could be a reliable alternative for the treatment of pediatric inguinal hernia.

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.

RETRACTED: A new technique for extraperitoneal repair of inguinal hernia

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief and authors, as portions of the clinical data used were inaccurate. Specifically, more than 500 cases of the total 1882 cases of hernia patients presented in the paper were actually hydrocele of tunica vaginalis, not hernia. The authors sincerely apologize for these errors.

The role of laparoscopy in children with groin problems

The use of laparoscopic surgery has grown dramatically in recent years in most all types of surgery. Historically, the early use of laparoscopic surgery was for pelvic and groin problems. In this article we review the current technique, indications, benefits and complications of laparoscopy in diagnosis and management of various groin problems in children including undescended testes (non-palpable and palpable) and inguinal hernia.

Risk factors for contralateral patent processus vaginalis determined by transinguinal laparoscopic examination

Concurrent contralateral inguinal exploration in children with unilateral hernia or hydrocele is a subject of debate. The aim of the present study was to investigate the incidence of contralateral patent processus vaginalis (CPPV) using transinguinal laparoscopy (inguinoscopy). In addition, the risk factors of CPPV were evaluated in order to facilitate the selection of appropriate candidates for contralateral examination. A total of 119 patients who presented with unilateral hydrocele, inguinal hernia or cryptorchidism between 2001 and 2008 underwent inguinoscopy during the ipsilateral surgery. All data were collected prospectively. The incidence of CPPV was investigated and the risk factors affecting the presence of CPPV were analyzed. Among these patients, 29 individuals (24.4%) had CPPV confirmed by inguinoscopy. No surgical complications were observed during the inguinoscopy. Cases with suspicious ultrasound findings were at a higher risk of CPPV than cases with normal findings (odds ratio, 13.800; P=0.004). A history of contralateral disease was also found to be a significant risk factor (odds ratio, 4.008; P=0.019). The present study identified that the significant risk factors for CPPV were suspicious findings on ultrasound examination and a history of contralateral disease. Therefore, it is concluded that performing inguinoscopy in children with these risk factors is beneficial.

Evaluation of the contralateral inguinal ring in clinically unilateral inguinal hernia: a systematic review and meta-analysis

PURPOSE

The management of the contralateral inguinal canal in children with clinical unilateral inguinal hernia is controversial. Our objective was to systematically review the literature regarding management of the contralateral inguinal canal.

METHODS

We searched MEDLINE, EMBASE, and Cochrane databases (1940-2011) using 'hernia' and 'inguinal' and either 'pediatric,' 'infant,' or 'child,' to identify studies of pediatric (age ≤21 years) patients with inguinal hernia. Among clinical unilateral hernia patients, we assessed the number of cases with contralateral patent processus (CPP) and incidence of subsequent clinical metachronous contralateral hernia (MCH). We evaluated three strategies for contralateral management: expectant management, laparoscopic evaluation or pre-operative ultrasound. Pooled estimates of MCH or CPP were generated with random effects by study when heterogeneity was found (I(2) > 50 %, or Cochrane's Q p ≥ 0.10).

RESULTS

We identified 2,477 non-duplicated studies, 129 of which met our inclusion criteria and had sufficient information for quantitative analysis. The pooled incidence of MCH after open unilateral repair was 7.3 % (95 % CI 6.5-8.1 %). Laparoscopic examination identified CPP in 30 % (95 % CI 26-34 %). Lower age was associated with higher incidence of CPP (p < 0.01). The incidence of MCH after a negative laparoscopic evaluation was 0.9 % (95 % CI 0.5-1.3 %). Significant heterogeneity was found in studies and pooled estimates should be interpreted with caution.

CONCLUSIONS

The literature suggests that laparoscopically identified CPP is a poor indicator of future contralateral hernia. Almost a third of patients will have a CPP, while less than one in 10 will develop MCH when managed expectantly. Performing contralateral hernia repair in patients with CPP results in overtreatment in roughly 2 out of 3 patients.

Simple maneuvers to reduce the incidence of false-negative findings for contralateral patent processus vaginalis during laparoscopic hernia repair in children: a comparative study between 2 cohorts

BACKGROUND

Transumbilical or transinguinal laparoscopic evaluation for contralateral patent processus vaginalis (CPPV) is commonly performed during laparoscopic or open hernia repair in children but may occasionally give false-negative findings.

METHODS

A retrospective study was conducted to compare 2 cohorts of children who underwent laparoscopic repair for clinically demonstrated unilateral inguinal hernia and evaluation for CPPV by transumbilical laparoscopy during the study periods of 2004 to 2007 (cohort 1) and 2008 to 2011 (cohort 2). Cohort 1 was a known historical cohort with CPPV being evaluated by laparoscopic inspection alone, whereas additional maneuvers were adopted in cohort 2.

RESULTS

There were 395 and 564 patients in cohorts 1 and 2, respectively. There was no difference between the 2 cohorts in age of patients, sex distribution, laterality of clinically demonstrated inguinal hernia, and follow-up period at the time of data collection. More CPPV were diagnosed in cohort 2 than cohort 1(36.2% vs 25.8%; P < .01). 4 children (1.4%) developed metachronous inguinal hernia following negative laparoscopic evaluation for CPPV in cohort 1 compared with none from cohort 2 at a similar median follow-up period (P < .05).

CONCLUSIONS

The additional maneuvers appear to be superior to laparoscopic inspection alone to evaluate CPPV during laparoscopic hernia repair in children.

One third of patients with a unilateral palpable undescended testis have a contralateral patent processus

PURPOSE

The purpose of this study was to determine the incidence and predictive factors associated with a contralateral patent processus vaginalis in boys with a unilateral palpable undescended testis.

METHODS

We retrospectively reviewed the records of 77 consecutive boys (median age, 15 months; range, 5 months to 17.7 years) who had undergone orchiopexy for a unilateral palpable testis. At inguinal orchiopexy, an 8F feeding tube and a 70° adult cystoscope lens were placed into the peritoneum through the hernia sac, and the contralateral internal ring was inspected. The clinical factors that might predict the presence of a contralateral patent processus vaginalis were determined.

RESULTS

The overall rate of a contralateral patent processus vaginalis was 34% in those with a significant ipsilateral hernia sac. After considering age, side, prematurity, location, and volume of the undescended testis, only the boys with a testis distal to the external ring compared with those with testes lying within the inguinal canal had statistically increased odds of a patent contralateral processus vaginalis (odds ratio, 3.1; 95% confidence interval, 1.08-9.08).

CONCLUSION

Approximately one third of boys with a unilateral palpable undescended testis will have a contralateral patent processus vaginalis as determined by transinguinal laparoscopy. The rate is higher (52%) if the undescended testis was distal to the external ring. Both the etiology and significance of this contralateral finding are unknown.

Incidence of pediatric metachronous contralateral inguinal hernia in children aged ≥1 year

BACKGROUND

The management of the contralateral asymptomatic side when a child with initial unilateral inguinal hernia undergoes herniorrhaphy continues to be controversial. Age less than 6 months at initial herniorrhaphy is considered as a high risk factor of the occurrence of metachronous contralateral inguinal hernia (MCIH). We performed herniorraphy for patients ≥1 year with initial unilateral hernia at one-day-set outpatient-surgery department without any intervention of contralateral groin. In this study, we reviewed the characteristics of development of MCIH in this condition and discuss the management strategies of MCIH.

METHODS

The subjects of this study were children who were treated at our outpatient-surgery department from January 2006 to December 2006. A total of 2129 patients with initial unilateral hernia and aged ≥1 year underwent an ipsilateral herniorhhaphy only. Patients were followed up for the development of MCIH to 60 months. The Chi-square test was used for intergroup comparison, a level of P<0.05 was considered as statistically significant.

RESULTS

Among these children 1341 (63.0%) were obtained 60 months follow-up data, 1146 (85.5%) were boys and 195 (14.5%) were girls. MCIH developed in 70 (5.2%) patients, 61 were boys and 9 were girls. In 570 patients aged 12-23 months, 43 developed MCIH (7.5%); in 564 patients aged 24-59 months, 21 developed MCIH (3.7%); and in 207 patients ≥60 months, 6 patients developed MCIH (2.9%), the difference between these groups was highly significant (P=0.004). In male patients, 30 right-sided MCIHs occurred after 423 initial left-sided herniorrhaphies (7.1%) and 31 left-sided MCIHs occurred after 723 initial right-sided herniorrhaphies (4.3%), difference between these two groups was significant (P=0.041). Seventy-seven percent of the MCIHs occurred within 1 year, 94% occurred within 2 years after initial herniorraphy.

CONCLUSIONS

As the overall incidence of MCIH in patients aged ≥1 year was 5.2%, routine contralateral groin exploration is not suggested. Transinguinal laparoscopy could be considered as an alternative of conventional "wait and see" policy, especially in patients less than 2 years or left-sided initial unilateral inguinal hernia. If "wait and see" policy is adopted, patients should be closely followed up for 2 years.

Systematic review for paediatric metachronous contralateral inguinal hernia: a decreasing concern

PURPOSE

Controversy still surrounds the treatment of the asymptomatic inguinal region in paediatric patients with a unilateral inguinal hernia. The concern is the development of a future metachronous contralateral inguinal hernia (MCIH) and therefore the need for a second operation. Our aim was to provide a current systematic review of the evidence for routine contralateral exploration, and identify potential at-risk groups.

METHODS

Comprehensive review of the literature utilising broad search terms to identify all relevant publications. Precise inclusion and exclusion criteria to identify studies that included paediatric unilateral inguinal hernia repair without routine contralateral exploration.

DATA ANALYSIS

Chi-square with Yates' correction or a Fisher's exact test as appropriate. Numbers needed to treat (NNT) calculated with 95% confidence intervals.

RESULTS

A total of 7,130 titles and abstracts were screened and 61 studies included with data on 49,568 paediatric patients with a unilateral inguinal hernia fulfilling the inclusion criteria. 2,857 of these patients later developed a MCIH, revealing an overall risk is 5.76% (95% CI: 5.55-5.97%). The NNT for a MCIH is 18 (95% CI: 16.8-18) with 18 contralateral exploration required for the prevention of one MCIH. Patients <6 months at the time of the initial intervention were more likely to develop a MCIH; 183/1,470 (<6/12) versus 144/2,044 (≥6/12), P < 0.0001. As were patients with an original left-sided hernia; 815/6,739 versus 865/12,615, P < 0.0001. The NNTs for both of these groups were 9. There was no association with the gender of the patient; 888/14,480 (♂) versus 268/4,206 (♀), P = 0.37.

CONCLUSIONS

There is insufficient evidence to support the routine contralateral inguinal exploration in all paediatric patients presenting with a unilateral inguinal hernia. However, with patients presenting with an originally left-sided hernia or who are less than 6 months old, a parental discussion should occur about the possible benefits and risks of contralateral exploration.

The contribution of intraoperative transinguinal laparoscopic examination of the contralateral side to the repair of inguinal hernias in children

BACKGROUND

Bilateral inguinal hernias are relatively common in children. This fact has led to a controversy of more than 50 years concerning the necessity of bilateral surgical exploration during the repair of unilateral inguinal hernias in children. The advent of transinguinal laparoscopic visualization of the contralateral side is a turning point and a major contribution to the subject, offering the opportunity to reassess the systematic bilateral exploration and the "wait and see" policies currently in use at most services of pediatric surgery.

DATA SOURCES

The current information concerning intraoperative transinguinal laparoscopic evaluation of inguinal hernias in children was summarized in a didactic way. A MEDLINE search (PubMed) from 1995 to the present days was conducted.

RESULTS

A patent processus vaginalis (PPV) is not equal to a future symptomatic hernia. There is still no definitive evidence on which PPVs will become a hernia (5.8% to 11.6%) and which remain clinically insignificant. Diagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side is today the most simple and accurate way to reduce the incidence of negative explorations.

CONCLUSION

Diagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side during pediatric inguinal hernia repair is a simple, accurate, fast, and effective method to assess the contralateral processus vaginalis, improving decision-making, reducing the number of negative explorations, and sparing the surgeon the embarrassment associated with the appearance of a metachronous hernia at a later date. It is easily learned and should be part of every pediatric surgeon's practice.

Laparoscopic contralateral groin exploration: is it cost effective?

BACKGROUND

Transinguinal laparoscopy offers a safe and effective method for evaluating the contralateral groin during unilateral inguinal hernia repair (UIHR). The purpose of this study is to determine whether laparoscopic contralateral groin exploration (LCGE) is cost effective.

METHODS

A retrospective review of all children who underwent UIHR and LCGE from 2006 to 2007 by a single surgeon was performed. Cost analysis comparing the time to perform the LCGE and time to repair the contralateral patent processus vaginalis (CPPV) to the cost saved by preventing future operation for a contralateral inguinal hernia repair was calculated based on Medicare reimbursement.

RESULTS

Eighty-one patients underwent UIHR with planned LCGE; 78 (96.3%) had successful LCGE; 8 (10.3%) had a CPPV and underwent contralateral open repair. The total cost for the additional time to perform LCGE and repair of the 8 CPPV was $13,080. The total cost for returning for a second operation to repair the contralateral inguinal hernia was $20,440.

CONCLUSION

Laparoscopic contralateral groin exploration at the time of unilateral inguinal hernia repair was cost effective.

A comparative study examining open inguinal herniotomy with and without hernioscopy to laparoscopic inguinal hernia repair in a pediatric population

AIMS

Open herniotomy with or without hernioscopy has been performed in our unit for a decade. Since 2005 the laparoscopic repair was also introduced. The aims of this study were: (1) to compare detection rates for direct visualization of the contralateral deep inguinal ring via the known sac using a 70 degrees scope and via umbilical 30 degrees laparoscopy and (2) to compare operative timings, metachronous and recurrence rates for the three different management pathways for inguinal hernia.

METHODS

A retrospective case note review was carried out over a 29 month period since the introduction of the laparoscopic hernia repair. All patients with inguinal hernia were identified from the work load of six surgeons encompassing the three methods of hernia management. Case notes were retrieved and the data analyzed using SPSS v.17.

RESULTS

A total of 308 patients had 326 hernias performed. Follow-up ranged from 3 months to 1 year (median 8 months). The male-female ratio was 4:1. Of the patients, 12% were neonates; 299 children presented with unilateral hernia. Of those, 164 (55%) children had open herniotomy without contralateral inspection, and 5 (3%) had metachronous hernia; 77 (26%) children had an open herniotomy with 70 degrees hernioscopy; 2 (3%) children, who were considered to have closed contralateral deep inguinal ring during hernioscopy, had metachronous hernia, and 58 (19%) children had a laparoscopic hernia repair and none of them had metachronous hernia. Detection of contralateral patent deep inguinal ring for 70 degrees hernioscopy and 30 degrees laparoscopy was 10 (13%) and 16 (28%), respectively (P = 0.0465). Operative timing was significantly longer for laparoscopic repair (P < or = 0.0001). During the study period there were 11 recurrences; 9 (5%) in the open only group and 2 (3%) in the laparoscopic group.

CONCLUSIONS

The results of the laparoscopic inguinal hernia repair are important for discussion as operative methods differ from that of herniotomy. The detection rate of contralateral patent deep inguinal ring appears to be higher for direct visualization via umbilical 30 degrees laparoscopy versus 70 degrees scope via the hernia sac. Whilst laparoscopy offers potential advantage of improved visualization, longer term prospective data collection is needed to compare these methods of operative hernia management.

Laparoscopic hernioplasties in children: the implication on contralateral groin exploration for unilateral inguinal hernias

BACKGROUND

Inguinal hernias are commonly seen in the paediatric population. Controversies still exist regarding the need for contralateral groin exploration when an unilateral inguinal hernia is presented, since the true incidence of contralateral patent processus vaginalis is not known. With the advent of laparoscopic hernioplasty, the status of the contralateral side can be evaluated at the same setting. Here, we describe our experience in this issue after the introduction of laparoscopic hernioplasty in our unit.

METHODS

A retrospective review was carried out between October 2002 and January 2008. All patients presented with unilateral inguinal hernias were included. The demographics of the patients and the operative findings at laparoscopy were recorded. Statistics were performed using Student t-test or chi(2) test as appropriate and p < 0.05 was taken as statistically significant.

RESULTS

During the study period, 363 children were included in our study, of which there were 292 males and 71 females. 212 patients presented with right-sided hernias and 151 were left-sided. The mean age of patients at presentation was 48.8 months. The incidence of contralateral PPV overall was 39.7%. There was no decrease in incidence of having a contralateral inguinal hernia in relation to age.

CONCLUSION

Laparoscopy can accurately diagnose contralateral PPV in children who undergo unilateral inguinal hernia repair and thus holds an advantage over open herniotomy. Furthermore, there should not be an age criteria for contralateral exploration for surgeons who perform open herniotomy.