Two Decades of History of Laparoscopic Pediatric Inguinal Hernia Repair

Dear Editor:

We read with interest the article by Ostlie and Ponsky ¹ titled “Technical options of the laparoscopic pediatric inguinal hernia repair,” published in the March issue of the Journal. In our opinion, this article provided an excellent but not complete overview of popular laparoscopic pediatric hernia repair techniques. From a historical perspective, some of the earliest work and published studies of pediatric laparoscopic hernia repair were performed in the early 1990s by Philippe Montupet and colleagues. In particular, the first intracorporeal laparoscopic hernia repair was performed by Philippe Montupet in 1993.

Montupet et al. ² published for the first time in a French journal, the Journal de Coeliochirurgie, on their first 3-year series (220 hernias) titled “Le traitement de la hernie inguinale congénitale chez l'enfant par coelioscopie: notes techniques.” Then Montupet published with co-workers two other articles on the same topic, in 1998 in Pediatric Surgery International ³ and in 1999 in the Journal of Pediatric Surgery. ⁴

As for the technique described by Montupet et al. ² (with the series beginning in 1993), the defect was closed performing a purse-string suture on the peri-orificial peritoneum at the level of internal inguinal ring with a nonabsorbable multifilament suture.

Montupet and Esposito ⁴ in 1999 modified and standardized the technique: the modification consisted in sectioning the peri-orificial peritoneum circumferentially, distally to the internal inguinal ring, before closing it with a purse-string suture. When the inguinal orifice is very large, >10 mm in diameter, a two-plane suturing technique can be used before closing the peri-orificial peritoneum. In order to reduce the diameter of the internal inguinal ring, one or two separate sutures can be positioned between the conjoined tendon and the crural arch. ⁵

The opening of the peri-orificial peritoneum with the use of monopolar coagulation performed according to Montupet's technique is a technical detail similar to the peritoneal injury created at the internal inguinal ring described by Ostlie and Ponsky ¹ in their current technique. We agree with the authors that this technical expedient does result in a more durable repair.

In 1998, 5 years after the introduction of Montupet's technique, Schier ⁶ described the second most popular intracorporeal technique, consisting of a “N”-shaped suture on the peri-orificial peritoneum. Both techniques give similar results; in fact, a multicenter survey, including 933 repairs, published by Schier et al. ⁷ in the Journal of Pediatric Surgery in 2002 (not reported in the references of Ostlie and Ponsky ¹ ) showed that these two techniques give similar results.

With both techniques, Montupet's and Schier's, there was a success rate of 98%–99%.^4,6

Montupet's technique gives also excellent results in newborns with incarcerated inguinal hernia. As reported by Choi et al. ⁸ and then by Esposito et al., ⁹ laparoscopic hernia repair in the newborn is feasible and safe and carries acceptable complication and recurrence rates.

Another weak point of the article by Ostlie and Ponsky ¹ is about the description of the laparoscopic techniques in regard to direct hernia repair. As reported by Esposito et al. ¹⁰ and Lima et al., ¹¹ to perform direct hernia repair, first of all, it is important to resect the hernia lipoma (always present); then the surgeon has to close the hernia defect eventually with the aid of bladder lateral ligament to reinforce the suture.

In conclusion, also, if the article by Ostlie and Ponsky ¹ describes accurately the most common laparoscopic techniques of pediatric inguinal hernia repair, we think that Montupet's technique, which has been adopted by many pediatric surgeons in Europe, has to be described to the readers of this Journal and should be cited here among intracorporeal techniques for correction of pediatric inguinal hernia via laparoscopy.