Reasons for Recurrence After the Laparoscopic Repair of Indirect Inguinal Hernia in Children

Introduction

Indirect inguinal hernia is a common condition in the pediatric age group that requires surgical repair. In China, both open and laparoscopic hernia repairs are conducted in most centers, but there has been an increasing trend toward laparoscopic hernia repair in more centers in recent years because of the rapid postoperative recovery times and excellent cosmetic appearance. In our hospital, laparoscopic hernia repair has been performed since 2008, and we now have an experience of more than 6000 patients. According to our follow-up records, although laparoscopic hernia repair is an effective treatment approach for indirect inguinal hernias in children, a small number of patients relapsed after surgery. Here we have described our experience and discussed the reasons for these recurrences.

Patients and Methods

From June 2008 to June 2013, 6120 cases of indirect inguinal hernia (5382 males and 738 females) were treated by laparoscopy in West China Hospital (Chengdu, China). The average age was 3.1 years (range, 3 months–14 years). Surgeons who perform these procedures undergo strict training. The pneumoperitoneum was established at the upper edge of the umbilicus (abdominal pressure maintained at 8–10 mm Hg) after general anesthesia was established, and a 5-mm trocar was placed for the laparoscopic lens. A 3-mm trocar for the clamp was placed at the lower edge of the umbilicus (Fig. 1), and this method is equivalent to a single-port approach. We initially inspected the internal rings bilaterally and then determined the surface projection of the unclosed internal ring. A sled-like needle with a folded nonabsorbable suture was inserted into the upper edge of the internal inguinal ring to encircle half of it at the extraperitoneum with the help of the clamp through the lower edge of the umbilicus, leaving the vas deferens and spermatic vessels unligated. Then, the sled-like needle with a second fold suture encircled the remaining half of the internal ring and pulled the first suture out of the skin, and the internal ring was ligated tightly (Figs. 2–4). The mean operation time was 7.3 minutes (range, 5–15 minutes). The volume of blood loss was minimal.

OPEN IN VIEWER

FIGS. 1–6.

(1) The sites of the trocars. (2) A sled-like needle with a fold suture was inserted into the upper edge of the internal inguinal ring. (3) A second fold suture encircled the remaining half of the internal ring and pulled the first suture out of the skin. (4) The incisions of laparoscopic hernia repair. (5) Recurrence beneath the original ligation. (6) An abdominal organ can slide down into the hernia sac.

Results

All of the patients were followed up postoperatively. To date, a total of 21 cases developed a recurrent hernia (0.3%), and all underwent a second surgery. Eighteen of these were conducted laparoscopically, and three underwent an open repair that included strengthening of the anterior wall of the inguinal canal. No second recurrences have occurred since.

Through our experience of the diagnosis and treatment of these cases of recurrence, we concluded that there were several surgical causes for hernial recurrences. First, hernias were more likely to relapse if the internal inguinal ring was significantly expanded compared with patients who did not develop a recurrence (1.95±0.86 cm versus 1.30±1.05 cm, respectively); those at particular risk had weakened inferior margins of the internal ring (Fig. 5). Children with persistent risk factors for hernia, such as cough, constipation, and diarrhea, were more likely to develop a recurrent hernia as the peritoneum surrounding the internal ring could slide down (Fig. 6), and hernial contents could then protrude (10 cases, 47.6%). Additionally, recurrent hernias were more likely if the sled-like needle perforated the peritoneum repeatedly, or some of the peritoneum around the internal ring might be left unligated in a very large hernia sac. This tended to occur if the operation was performed by an inexperienced surgeon. Generally, this type of relapse caused a hydrocele (9 cases, 42.8%). Finally, the unexpected release of the ligature around the hernial ring may have occurred shortly after the surgery if the residual cord of the knot was too short (2 cases, 9.6%). In all cases of recurrence, a double ligation of the internal ring was made to prevent further unexpected loosening.

Discussion

Compared with the open indirect inguinal hernia repair, laparoscopic hernia repair has several advantages. The incisions are smaller and more concealed, the hernial sac (or tunica vaginalis) is easier to find, and the contralateral internal ring can be explored, among other factors. With improvements in skill and experience, the operation time required for the laparoscopic hernia repair is comparatively short. In this group, the mean operation time was approximately 7.3 minutes, which is shorter than an open hernia repair. ¹ The amount of blood loss in laparoscopic hernia repair is also very small. The complications related to pneumoperitoneum, such as acidosis and subcutaneous emphysema, are very rare. It is also safe for small babies and patients with an incarcerated inguinal hernia.^2–4 Therefore, the use of laparoscopic hernia repair has spread widely in China.

From our data of laparoscopic hernia repair, the recurrence rate was quite low. According to the literature, ⁵ the recurrence rate of the open indirect inguinal hernia repair was 1%–2.5%. So the laparoscopic hernia repair was able to obtain better results. ⁶ Probably it was related to clear exposure of the internal ring and less damage to the inguinal canal. Moreover, it is important that the laparoscopic surgery can provide much useful information with regard to relapse causes of inguinal hernia.

In our cohort, the main cause of hernial recurrence was an expanded and weakened internal inguinal ring. In general, the fascia transversalis and the abdominal muscles are smaller in cases that recur, especially in younger children. When a risk factor for herniation existed, as was the case in approximately 80% of patients who had a recurrent hernia in this study, such as a chronic cough, constipation, or diarrhea, then the hernial contents can protrude around the original ligation, particularly underneath the internal inguinal ring where there is a lack of muscle. Usually, we could see a new orifice beside the original ligation (Fig. 5). The relapse time was usually 6 months after the original surgery when the scar was softened; the age of relapse was often during the preschool period, and the probable contributing causes included restless activity and weak inguinal muscles during this age range.

The majority of recurrent hernias can be cured by laparoscopic hernia repair after any risk factors are removed. However, for a small number of children, additional strengthening of the inguinal canal wall was required. For example, a bilateral hernia was repaired by laparoscopy in a 3-year-old boy, but the left side relapsed 6 months later, and a secondary surgery was necessary. During this operation, we checked the contralateral internal ring routinely and found no abnormalities. However, 3 months later, a hernia on the right side recurred. Considering that the inguinal canal was weak, we re-operated using a classic Ferguson's open repair, and no further relapse has occurred to date. From that point, when encountering recurrence and weakness of the abdominal wall of children, we preferred to use an open approach to perform a high ligation of the hernial sac and to strengthen the anterior inguinal canal wall.

Although the majority of pediatric inguinal hernias result from abnormal developmental processes, strengthening of the inguinal canal was necessary in some recurrent cases. From this point of view, these behaved somewhat like adult inguinal hernias. Furthermore, in some recurrences that were repaired by laparoscopy, we also found that some of the retroperitoneum involving a part of the cecum with the appendix could slide down into the hernia sac (Fig. 6).

From our experiences with 21 cases of hernia recurrence, we have been able to deduce the most common causes for recurrence. This investigation will enable us to select the most appropriate approach for inguinal hernia repair that will prevent relapses postoperatively.