Is There an Increased Risk of Complications with Laparoscopy Looking for a Contralateral Patent Processus Vaginalis?

Abstract

Background:

In young children with a unilateral congenital inguinal hernia, the relatively high incidence of an occult contralateral patent processus vaginalis (CPPV) has led to the practice of laparoscopic contralateral exploration. The effect on postoperative complications such as surgical site infection from performing the laparoscopy has not been previously reported.

Patients and Methods:

A retrospective review was conducted on all patients who underwent a unilateral inguinal hernia repair from January 1, 2000 to March 1, 2010. We compared those children who underwent laparoscopic evaluation of the contralateral inguinal ring with those who did not. Patient demographics and operative data outcomes were evaluated. Student's t test was used to compare continuous variables, and the chi-squared test with Yates's correction was used for discrete variables.

Results:

There were 1164 patients who underwent a unilateral inguinal hernia repair during the 10-year study period, and laparoscopy was used in 1010 patients. There were no intraoperative complications from the laparoscopy. In the group who underwent laparoscopy, the mean age was 4.0±3.6 years old, and 88% were male. At laparoscopic exploration, 315 (31%) patients were found to have a CPPV. There were 10 patients (1.0%) who developed a surgical site infection. Infection developed in the side used for laparoscopic exploration in 9 patients and in the contralateral side in 1 patient. All patients with surgical site infections were treated initially with oral antibiotics. Abscesses developed in 2 patients, requiring incision and drainage. No patient required hospital admission or reoperation. In the 154 patients who did not undergo laparoscopy, mean age was 4.3±4.4 years (P=.35), and 85.8% were male (P=.54). There was one wound infection identified in this control group (0.6%) (P=1.00). There was no difference in rate of recurrence (control group, 0%; exploration group, 0.6%; P=.72).

Conclusions:

There is minimal risk of infection or recurrence following unilateral inguinal hernia repair, and this risk is not increased with the use of contralateral exploration using laparoscopy.

Background

In children diagnosed with a unilateral inguinal hernia, the risk of finding a contralateral patent processus vaginalis (CPPV) has been reported as 30%–40%.¹ Routine contralateral inguinal exploration in patients with a known unilateral inguinal hernia has been decreasing as the use of laparoscopic evaluation of the contralateral side through the hernia sac has gained popularity.² The use of laparoscopic evaluation on the contralateral side allows for the identification of patients with a CPPV without subjecting patients to the added morbidity of an unnecessary contralateral exploration. However, there are few reports evaluating if there is increased morbidity for the ipsilateral side when the diagnostic laparoscopy procedure is performed through the known hernia sac. In this article, we examine the effect of laparoscopic evaluation of the contralateral side on the rate of ipsilateral surgical site infection.

Patients and Methods

A retrospective review was conducted on all patients who underwent a unilateral inguinal hernia repair from January 1, 2000 to March 1, 2010. Patients were divided into two groups: those who underwent laparoscopic evaluation of the contralateral side through the hernia sac and those who did not. In order to establish a sample for comparison, the patients in the nonscoped group were a consecutive series during the same time period from the experience of a single surgeon who does not use laparoscopy. This prevented comparing the scoped patients with those who would not have been scoped for a reason that would create bias. Patients with known bilateral inguinal hernias were excluded. Patient demographics, preoperative, and operative data outcomes were evaluated. Outpatient postoperative follow-up data included complications, subsequent admissions or procedures, and hernia recurrence. Student's t test was used to compare continuous variables, and the chi-squared test with Yates's correction was used for discrete variables.

Results

There were 1164 patients identified with a unilateral inguinal hernia during the study period. Demographics and laterality were no different between the laparoscopic and control groups (Table 1).

Table 1.

Patient Demographics by Group

	Unilateral repair	Unilateral repair with laparoscopic exploration	P value
Number of patients	154	1010
Mean age (years)	4.3±4.4	4.0±3.6	.35
Male	132 (85%)	887 (88%)	.54
Hernia side
Left	60 (39%)	376 (37%)	.75
Right	94 (61%)	634 (63%)

Contralateral laparoscopic exploration was performed in 1010 patients, of whom 31% were found to have a CPPV. In all of these patients, repair of the CPPV was subsequently performed using an open technique. If laparoscopy showed no patent processus vaginalis, contralateral repair was not done. Of these patients, 63% presented with a right inguinal hernia. In this group, there were 10 patients (1.0%) who developed a surgical site infection. A wound infection occurred on the side of the known inguinal hernia in 9 patients. All patients were started on oral antibiotics. Abscesses requiring incision and drainage occurred in 2 patients. No patient required hospital admission or reoperation. The mean number of clinic visits for patients who developed a surgical site infection was two visits. There were 6 (0.6%) hernia recurrences, all on the side of laparoscopic exploration; of these, 5 were negative for contralateral hernia.

In the 154 patients who underwent unilateral inguinal hernia repair without laparoscopic exploration, 1 patient (0.6%) developed a surgical site infection that was treated with oral antibiotics. This patient had two clinic visits after his initial hernia repair. From the available medical record data, there were no hernia recurrences in this group.

There were no statistical difference in the wound infection rate (P=1.0) or hernia recurrence rate (P=.72) between those who underwent laparoscopic contralateral exploration and those who did not.

Discussion

The objective of this study was to evaluate the effect of the additional instrumentation of the hernia sac with the laparoscope during contralateral groin exploration on the rate of infection and hernia recurrence. A 2005 survey by the American Academy of Pediatrics Section on Surgery demonstrates 37% of surgeons perform laparoscopic evaluation for contralateral inguinal hernias compared with only 6% in 1993, suggesting a rising trend in laparoscopic evaluation of CPPV.³ Complications after this operation are typically quite low regardless. Demographics of the cohort of patients captured in this study closely resemble those reported in the literature, with a 9:1 male-to-female ratio and a 60% right-sided hernia preference.^4–7 The incidence of a CPPV in the subgroup of patients who underwent laparoscopic exploration was 31%, which is also in the previously reported range of 30%–40%.^1,8–10

We found that the patients who underwent laparoscopic evaluation for a CPPV had a wound infection rate of 1.0%, which was not significantly different from that of the nonexplored group. In 1 of these patients, the wound infection occurred on the contralateral side, which is most likely unrelated to the laparoscopy. Despite the smaller size of the comparison group for the group who underwent diagnostic laparoscopy, wound infection rates in both groups approximate published rates for surgical site infection after inguinal hernia repair.^11,12 In a retrospective study of 77 patients with laparoscopic exploration, no difference was seen in wound infection rate with diagnostic laparoscopy (1.3%) compared with open repair alone (1.7%).¹³ Wound infection rates as high as 2.1% have been reported after laparoscopic exploration.¹⁴

Not only was the rate of wound infection the same between groups, but severity of wound infection was also similar. This demonstrates that the additional manipulation of the sac and work within the canal do not affect the risk of infection. The clinical course for surgical site infections after this operation was indolent regardless of laparoscopy with no patients in either group requiring additional anesthetic or sedation for definitive management.

The increased manipulation of the hernia sac during laparoscopic exploration may theoretically increase the risk of recurrence, perhaps from injury to the sac. The recurrence rate of 0.6% reported here approximates previous reports of a 0.3% recurrence following manipulation of the sac for contralateral exploration.¹⁵

Conclusions

The utilization of laparoscopic evaluation of the contralateral side during inguinal hernia repair allows for the diagnosis of previously occult CPPV without increasing the risk of surgical site infection or hernia recurrence.

Footnotes

Disclosure Statement

No competing financial interests exist.

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