Microlaparoscopic hernia repair in children: initial experiences

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic vs. laparoscopically assisted pediatric inguinal hernia repair: a systematic review

This systematic review aims to compare the two major principles of laparoscopic pediatric inguinal hernia repair: totally laparoscopic repairs (LR) and laparoscopically assisted repairs (LAR), to find out the optimal approach for pediatric patients. A systematic literature search was performed via Pubmed, Embase MEDLINE, and Cochrane databases on all studies published in the last 20 years reporting outcomes on these principles including recurrences, complications, and operative time. Prospective studies for either principle or retrospective comparative studies were considered eligible. Fischer's exact and Student's t test were used for statistical analysis with p value < 0.05 considered statistically significant. Twenty-one studies, including two thousand one hundred and ninety-six patients (LR: 1008), of ages ranging from 9 days to 18 years-old and a male to female ratio of 2.55:1, met our inclusion criteria. Follow-up period varied from 3 months to 8 years. Recurrence rates were similar between the two categories (LR: 1.68% vs. LAR: 1.59%, p > 0.05). As regards post-operative complications, transient hydrocele development was higher in laparoscopic repairs (LAR: 1.01% vs. LR: 3.17% p < 0.005) while wound healing problems were more frequent in laparoscopically assisted repairs (LAR: 1.17% vs. LR: 0.30%, p = 0.019). Mean operative time was lower in laparoscopically assisted repairs both in unilateral (LAR: 21.49 ± 13.51 vs. LR: 29.73 ± 11.05, p = 0.131) and bilateral cases (LAR: 28.01 ± 15.08 vs. LR: 39.48 ± 16.35, p = 0.101) but without statistically significant difference. Both principles are equally effective and safe as their recurrence and overall complications rates are equivalent. Transient hydrocele occurs more often in laparoscopic repairs while wound healing problems are associated mostly with laparoscopically assisted repairs.

Laparoscopic inguinal hernia repair in bladder exstrophy, a new modified solution to an old problem: A cohort study

PURPOSE

Open inguinal hernia repair in children with bladder exstrophy is challenging and associated with a high recurrence rate (15%-22%). We report our initial experience with laparoscopic repair of inguinal hernias in five children with repaired bladder exstrophy. This study is the third describing inguinal hernia repair in bladder exstrophy patients using the laparoscopic approach. In this study, we report a different laparoscopic technique.

METHODS

This retrospective study was performed on data regarding laparoscopic inguinal hernia repair collected over one year (July 2019-2020). We carried out the laparoscopic inguinal hernia repair, closing the internal inguinal ring using a non-resorbable sliding knot suture and incorporating the transversalis fascia for reinforcement, followed by purse-string closure of the peritoneum. Peri- and postoperative outcome parameters, including recurrence rate, were evaluated over a follow-up period of 14 months.

RESULTS

A total of seven male patients from July 2019 to 2020 were admitted to our center with a history of repaired bladder exstrophy and reducible inguinal hernias. Two patients had open inguinal hernia repair due to parental preference and five patients had laparoscopic repair. In the laparoscopic group three patients had bilateral inguinal hernias in one of them a metachronous hernia was discovered intraoperstively, and the remaining two patients had unilateral hernias, one on the right side and the other on the left side. All patients in the laparoscopic group had an uneventful recovery and were discharged within 24 h and there were no complications or recurrences during follow-up.

CONCLUSION

Laparoscopic inguinal hernia repair is a better alternative to managing inguinal hernias in children with bladder exstrophy.

Derivation of a complication burden score based on disability-adjusted life years to assess patient burden following surgery: a pilot study

BACKGROUND

Comparing adverse outcomes following alternative surgical interventions is a complex process for both patients and providers. Disability-adjusted life years (DALYs) are used globally as a quantitative indicator of burden of disease. However, DALYs have not been applied to the burden of postoperative complications. This study explores the feasibility and utility of DALYs in measuring the burden of postoperative complications, using 2 pediatric surgical procedures as a test model.

METHODS

A literature review was undertaken of postoperative complications following pediatric inguinal hernia repair and intestinal atresia repair. Relevant studies were included, and incidence rates and durations of all key complications were identified. Using existing disability weights of equivalent health states to the complications, we estimated the burden in DALYs of each complication. These estimates were combined into a unitary procedure-specific complication burden score.

RESULTS

The key complications contributing to the postoperative burden following inguinal hernia repair were recurrence (0.016 DALYs), hydrocele (0.010), metachronous hernia (0.014) and port-site hernia (0.012). In the case of intestinal atresia repair, death (6.278), reoperation (12.100), stenosis (5.025) and anastomotic stricture (5.327) accounted for most of the postoperative DALYs. The complication burden score was 0.06 DALYs for inguinal hernia and 36.86 for intestinal atresia repair.

CONCLUSION

As a proof of concept, this study supports the feasibility of using DALYs to derive a complication burden score following surgical intervention, and to our knowledge it represents the first application of burden of disease metrics to postoperative adverse outcomes. Future studies should focus on deriving de novo disability weights for common postoperative complications and adverse outcomes.

A 9-year experience study of single-port micro-laparoscopic repair of pediatric inguinal hernia using a simple needle

Purpose

As laparoscopic techniques and equipments improve, laparoscopic inguinal hernia repair has been gaining popularity. The objective of the study was to summarize 9 years of experience using a single-port micro-laparoscopic approach to repair pediatric inguinal hernias with a simple hernia needle.

Methods

1880 children with inguinal hernias were enrolled using micro-laparoscopic surgery between June 2009 and 2018. All patients underwent high ligation surgery using a single-port micro-laparoscopic technique. The clinical data were retrospectively analyzed.

Results

All micro-laparoscopic surgeries were successfully performed in the 1880 patients, who ranged in age from 2 months to 14 years (3.66 ± 2.96 years) including 1622 males and 258 females. Among them, 1299 cases were unilateral hernias and 581 cases were bilateral hernias. The average operating time was 12.5 ± 3.5 min for a unilateral hernia and 20.5 ± 4.5 min for bilateral hernias. All patients were discharged 1–2 days after surgery, and the average length of their hospital stay was 2–4 days. Complications of knot reaction and pneumoscrotum occurred in 5 cases (0.27%) and 54 cases (2.87%), respectively, but these cases were properly managed, with no major impact on the operational outcomes. All patients were followed up for 3–65 months; there were 13 recurrent cases (0.69%).

Conclusions

Single-port micro-laparoscopic herniorrhaphy in children using a simple hernia needle is a reliable and minimally invasive procedure.