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

Analysis of Techniques in Laparoscopic Inguinal Hernia Repairs across Pediatric Age Groups: EUPSA Trainees of European Pediatric Surgery Survey

AIM

 This survey analyzed techniques in laparoscopic inguinal hernia repair (LIHR) across pediatric age groups.

MATERIALS AND METHODS

 Data were collected through an online survey for pediatric surgeons, comprising of 38 questions, conducted by the European Pediatric Surgeons' Association (EUPSA) Trainees of European Pediatric Surgery (TEPS) LIHR Working Group.

RESULTS

 The survey was completed by 183 surgeons from 22 countries. Seventy-seven percent of respondents had performed LIHR at least once. Regarding preferences about the patient's gender, 7% respondents perform LIHR only in selected females, 9% routinely in females, 15% in both genders with age/weight restrictions, 24% routinely in both genders, 31% in selected cases, and 14% never perform LIHR. Percutaneous internal ring suturing (PIRS) was the preferred technique in all age groups, with totally extraperitoneal and transabdominal preperitoneal repairs preferred by 9% in adolescents. The majority (59%) repaired a contralateral patent processus vaginalis if present. Hydro-dissection (21%) and additional intra-abdominal instruments (42%) were preferred more often for male patients. The distal hernia sac was left intact by most respondents (92%). Responses regarding recurrence rates varied: 40% responded that LIHR had recurrence rates comparable to open surgery, whereas 10% reported increased recurrences and hence limited its use, and 10% consider that slightly increased recurrences are outweighed by lower complication rates associated with laparoscopic methods and thus continue LIHR.

CONCLUSIONS

 PIRS is the preferred choice for pediatric LIHR. Surgical techniques vary and are influenced by patient gender and age. The survey gives insights into demographics, case selection, and approaches among pediatric surgeons with regard to LIHR.

Comparison of low and standard pneumoperitoneum pressure in laparoscopic pediatric inguinal hernia repair

Introduction

The effectiveness and safety of low pneumoperitoneum in laparoscopic pediatric inguinal hernia repair is unclear and required to explore.

Aim

To evaluate the benefits of low (LPP) vs. standard pneumoperitoneum pressure (SPP) in laparoscopic pediatric inguinal hernia repair.

Material and methods

We performed a retrospective cohort analysis of patients with pediatric inguinal hernia. The patients were divided into LPP and SPP groups. Anesthesia and postoperative characteristics were analyzed.

Results

We enrolled 169 eligible patients in this study. Anesthesia and postanesthesia care unit times in the LPP group were lower than those in the SPP group (p = 0.00, p = 0.01, respectively). The LPP group had lower values for peak partial pressure of end-tidal carbon dioxide (PETCO2; mm Hg) (33.37 ±4.09 vs. 36.56 ±4.08), trough PETCO2 (38.33 ±5.04 vs. 40.46 ±4.14), and PETCO2 at the end of surgery (35.29 ±4.59 vs. 38.76 ±4.22). The LPP group required less sufentanil citrate (8.76 ±4.07 ml vs. 18.03 ±16.04 ml) and midazolam (1.56 ±0.45 ml vs 1.79 ±0.59 ml) vs. the SPP group, respectively. There was no significant difference between the groups regarding postoperative complications.

Conclusions

LPP was associated with shorter anesthesia and postanesthesia care unit times, and lower PETCO2 values compared with SPP. Compared with the SPP group, the LPP group had comparable operation times and postoperative complications. However, long-term outcome studies are needed.

Comparison of Percutaneous Internal Ring Suturing (PIRS) versus Open Ligation of the Patent Processus Vaginalis for the Treatment of Communicating Pediatric Hydrocele

BACKGROUND

Although the laparoscopic approach become standard for the treatment of many surgical conditions many studies still debating whether laparoscopic surgery has significant advantages over open surgery in regards to hernia or hydrocele treatment. This study aimed to evaluate the outcomes of treatment of treatment of communicating hydrocele in pediatric patients between laparoscopic percutaneous internal ring suturing (PIRS) and open ligation of the patent processus vaginalis (PPV).

METHODS

The medical records of pediatric patients who underwent surgery for communicating hydrocele between 1 January 2019 and 1 January 2024 were retrospectively reviewed. The primary objective of the study is to investigate the outcomes of treatment (complications and recurrence rates) of communicating hydrocele in children between laparoscopic and open surgical approaches. Secondary outcomes of the study are the duration of surgery and anesthesia, length of hospital stay (LOS), frequency of hospital readmissions (ReAd) and unplanned return to the operating room (uROR).

RESULTS

A total of 198 children underwent surgery for a communicating hydrocele (205 repairs, as 7 cases were bilateral) and were included in the study. Of these, 87 children underwent a PIRS, while the remaining 111 cases underwent open ligation of the PPV. No recurrence of the hydrocele was observed in any of the study groups. Intraoperative complication (epigastric vein injury) was noted in two cases in both groups (2.3% vs. 1.8%, p > 0.999). A slightly higher number of postoperative complications was observed in the open group (n = 7, 6.3%) compared to the PIRS group (n = 2, 2.3%) (p = 0.190). The median duration of surgery (15 min (IQR 10, 17) vs. 21 min (IQR 15, 25); p < 0.001) and anesthesia (30 min (IQR 25, 40) vs. 40 min (IQR 35, 40); p < 0.001) were significantly lower in the PIRS group compared to open ligation of the PPV. In addition, a significantly shorter median of LOS was observed in the PIRS group compared to the open PPV group (9 h (IQR 8, 12) vs. 24 h (IQR 12, 24; p < 0.001). No cases of ReAd and uROR were observed in any of the study groups.

CONCLUSIONS

PIRS is a safe and effective laparoscopic technique that can be used in the treatment of communicating hydrocele in children. PIRS showed excellent outcomes and a low incidence of complications and recurrences, comparable to traditional open surgery.

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.

Efficacy of a modified needle grasper for single-port laparoscopic hernia repair in children: a propensity score-matched analysis

PURPOSE

The advantage of using the single-port technique over the conventional two-port approach is uncertain. This study aimed to evaluate the outcomes of a single-port laparoscopic percutaneous extraperitoneal closure (SLPEC) using a modified needle grasper in children and compare the results to those of two-port laparoscopic percutaneous extraperitoneal closure (TLPEC).

METHODS

A retrospective cohort analysis of SLPEC and TLPEC surgery from February 2016 to June 2021 was conducted at our institution. Pediatric patients underwent SLPEC using the modified needle grasper to complete the high ligation of the hernia sac, while operations in the conventional two-port group only used regular laparoscopic instruments. A 1:1 propensity score matching (PSM) analysis was used to reduce selection bias.

RESULTS

Of 1320 patients, 1169 were included in the single-port/two-port crude evaluation, with 930 in the PSM cohort (465 patients/arm). Among 1:1 matched patients, the operation time for single-port patients vs. two-port patients were 11.28 ± 3.98 vs. 15.47 ± 4.54 min for unilateral repair and 16.86 ± 4.59 vs. 20.40 ± 4.29 min for bilateral repair (p < .05). Cosmetic results did not differ between the SLPEC and TLPEC groups (0% vs. 0.7%, p = 0.249). The recurrence rates were comparable between the two groups (0.6% vs. 1.1%, p = 0.725). Moreover, the differences in surgical site infection (SSI), testicular atrophy, open conversion and postoperative hydrocele occurrence were insignificant between the two groups.

CONCLUSIONS

In this cohort study, the modified needle grasper is a safe and feasible instrument for SLPEC, and SLPEC using the needle grasper has a shorter operation time than TLPEC.

Percutaneous Internal Ring Suturing for the Minimally Invasive Repair of Congenital Inguinal Hernia in Neonates: A Retrospective Cohort Study

Introduction Inguinal hernia (IH) repair is among the most frequently performed surgical operations in children. While open herniorrhaphy has been the gold standard surgical method of choice, the popularity of laparoscopic repair has sharply risen over the past two decades. Although a wide range of literature on the use of laparoscopy for IH repair in children exists, data regarding neonates, an especially delicate group of children, is limited to only a few studies. This study aims to evaluate the surgical, anaesthetic, and follow-up data of term neonates undergoing percutaneous internal ring suturing (PIRS) for IH repair in order to determine if it is a viable option for this specific patient population. Materials and methods This single-centre retrospective cohort included all children who underwent PIRS for IH repair during an 86-month period between October 2015 and December 2022. Patients' gender, gestational age at birth, age and weight at surgery, side of IH at diagnosis, per-operative findings (presence of contralateral patent processus vaginalis (CPPV)), surgical time, time under anaesthesia, follow-up time, and follow-up findings were collected from an electronic database and analysed. The primary outcome measures were surgical time, rate of recurrence, and presence of CPPV and the secondary outcome measures were anaesthesia time and the rate of complications. Results During the study period, 34 neonates (23 male and 11 female) underwent laparoscopic repair for IH using the PIRS technique. Average age and weight at surgery were 25.2 ± 3.2 (20-30) days and 3530.4 ± 293.6 (3012 - 3952) gm, respectively. IH was detected on the right side in 19 (55.9%), on the left side in 12 (35.3%), and bilaterally in three (8.8%) patients at their presenting physical examination. Nine patients (26.5%) were found to have CPPV perioperatively, which were all repaired simultaneously. The average surgical time was 20.3 ± 4.5 minutes for unilateral and 25.8 ± 4.0 minutes for bilateral IH repair (p<0.01). On the contrary, the average time under anaesthesia was 33.2 ± 4.5 minutes for unilateral and 33.5 ± 4.9 minutes for bilateral IH repair, but the difference was not statistically significant (p>0.05). No early postoperative complications were observed. The average follow-up time was 27.6 ± 14.4 (range: 3-49) months. Recurrence was seen in one patient (2.9%) and umbilical incision granuloma was observed in two (5.9%) patients. Conclusion Surgical times, anaesthesia times, complication rates, recurrence rates, and rate of CPPV in neonates undergoing PIRS are similar to those in older children and comparable to those of open herniorrhaphy and other laparoscopic techniques. Despite the suspicion that the rate of CPPV would be higher in neonates, we found that it is similar to that in older children. We conclude that PIRS is a viable option for the minimally invasive repair of IH in neonates.