Pediatric Laparoscopic Inguinal Hernia Repair: A Review of the Current Evidence

Abstract

Introduction

Minimally invasive surgical (MIS) approaches to nearly all pediatric surgical conditions are becoming part of the armamentarium of most pediatric surgeons. This is true for the management of pediatric inguinal hernia repair, with a variety of laparoscopic techniques being reported over the last decade. However, the widespread adoption of the laparoscopic approach for inguinal hernias in infants and children among pediatric surgeons remains to be seen. This delay is attributed to concerns regarding the potential for higher recurrence rates, increased cost, longer operative time, and need for advanced surgical skill training, as well as with a lack of significant comparable benefit over the traditional open hernia repair.¹ In contradistinction to these concerns, some literature suggests that the laparoscopic hernia repair has several advantages, including minimal dissection (decreased risk for vas injury), fewer complications, superior visual exposure, easy alternative to incarcerated, recurrent, or preemie hernias, comparable recurrence rates, and improved cosmetic results.^2–4 Furthermore, the laparoscopic approach allows for laparoscopic evaluation of the contralateral internal inguinal ring for the presence of a patent process vaginalis (PPV), with repair of the contralateral hernia during the same operation.^1,5

It is not surprising that over the last several years there has been growing interest by numerous groups around the world in improving the laparoscopic technique while simultaneously addressing the concerns noted above. The results of these studies have shown that the laparoscopic approach is safe and effective. As expected, the traditional open hernia repair is considered the gold standard with which laparoscopic techniques should be compared. However, the open approach does have associated disadvantages as well, including inability to evaluate the contralateral internal ring and a reported recurrence rate of 1%–5%.⁶ Furthermore, the open repair can be challenging in certain cases such as recurrent hernias, incarceration, hernias in premature infants, and obese adolescent patients. Finally, in a report with 50-year follow-up on childhood inguinal hernia repair from the Mayo Clinic, the most common cause of recurrence after open high ligation was found to be a direct hernia.⁷ This raises the question of the possibility that a predisposition to a direct hernia is created subsequent to open high ligation, as well as the potential for misdiagnosis at the time of repair. The laparoscopic approach allows for prevention of both of these possibilities. With these points in mind, it's not unreasonable to consider the laparoscopic approach as a possible alternative to open hernia repair.

This article is a review of the history and current literature on the laparoscopic approach to pediatric inguinal hernia repair in infants in children. It reports the current state of laparoscopic inguinal hernia repair and will provide surgeons with the most recent data to assist them in their decision of whether to approach these repairs in a minimally invasive fashion.

History

Over 100 years ago, the technique of high ligation was described, and it has been shown to be highly effective. As recently as 15 years ago, the practice of contralateral inguinal exploration at the time of open inguinal hernia repair to evaluate and repair a contralateral PPV/inguinal hernia was commonplace. In an effort to eliminate the contralateral exploration, Lobe and Schropp⁵ first reported the use of a laparoscopic approach in the repair of inguinal hernia in children in 1992. In this report, they documented performing a diagnostic laparoscopic evaluation for visualizing the internal rings using a 2-mm scope prior to performing open hernia repair. Subsequent to this publication, there have been numerous series documenting the efficacy of laparoscopic evaluation for the contralateral PPV.^8,9 The use of laparoscopy to evaluate the internal rings, coupled with the expansion of laparoscopic surgery in infants and children and the development of laparoscopic inguinal hernia repair in adults, eventually led to approaching inguinal hernia repair in the pediatric patient via the laparoscopic route.

The initial response to laparoscopic inguinal hernia repair in the pediatric population was one of speculation and concern. This was not dissimilar to a multitude of other MIS techniques for common surgical conditions in this population, including appendectomy, pyloric stenosis, and orchiopexy for intraabdominal testis. Specifically, pediatric surgeons were comfortable with the open approaches that were “tried and true,” were reproducible, had low complication rates, and were effective. Additionally, as with nearly all MIS procedures, a learning curve was present during the early stages, during which time the surgeon remained more comfortable with the open approach, which was often quicker than the MIS approach during the learning curve. Finally, questions existed about whether the laparoscopic approach was as safe or effective as the open repair.¹

Although the laparoscopic approach was not initially widely accepted, there were numerous individuals and institutions that continued to perform the repair in an MIS fashion. Eventually this led to reports of the safety and efficacy of the MIS laparoscopic hernia repair in infants and children. Probably the first report of a laparoscopic approach for hernia repair in the pediatric population was in 1998, when Schier¹⁰ reported the successful management of inguinal hernias in 14 girls. Although not reported until 2006, the laparoscopic extraperitoneal closure for pediatric hernias was initially used as early as 1995.¹¹ In 1999, Montupet and Esposito¹² published the initial experience with laparoscopic treatment of congenital inguinal hernia in male children. Finally, there have been several retrospective reports that document acceptable operative times ranging from 5 to 21 minutes for the actual repair and from 8 to 35 minutes from incision to closure.^4,11–16

These reports have provided the basis upon which the spectrum of MIS approaches to inguinal hernias in children has been developed, as they were first to conclude that the technique was safe and feasible.

Current Evidence

The laparoscopic approach to the repair of inguinal hernia in children has certainly gained popularity over the last several years as evidenced by the increase in the number of case series showing success, as well as variations in techniques. However, concerns still exist about its ultimate role in the pediatric population.

Despite these concerns, there is an increasing body of evidence in favor of the technique. There is no argument against the fact that the laparoscopic technique grants the unequivocal opportunity for the surgeon to directly visualize the internal inguinal ring without dissection of the abdominal wall. There is evidence to show that a clinical diagnosis of hernia is not always commensurate with what is directly visualized by the surgeon through a laparoscope.⁴ With direct visualization, explicit diagnosis and treatment are able to be carried out. This direct visualization has essentially eliminated the consequences of wrong-side surgery.

Similarly, the ability to visualize the contralateral internal ring from the umbilical position has been shown to be superior to either clinical exam or extension of pneumoperitoneum into the scrotum and avoids the difficulties that can be encountered with the laparoscopic evaluation using the transinguinal approach.^8,17 In the largest reported consecutive series of 1676 patients undergoing laparoscopy for evaluation of the contralateral internal ring, 40% of the patients were found to have a PPV.⁸ In this study all patients were examined after the induction of anesthesia by an attending pediatric surgeon, at which time it was predicted that 28% would have a PPV. It is interesting that the authors reported that the physical examination accurately predicted the presence of a PPV only 43% of the time. Our ability to determine that there is no PPV was slightly better at 61%; however, this highlights that if we based the decision on the absence of a PPV on exam, we would be incorrect 39% of the time.

Although the ability to visualize the contralateral internal ring via the transinguinal approach is generally accomplished without significant difficulty, some have suggested that alternative techniques are needed to ensure visualization. It has been reported that more than 20% of the time the contralateral internal ring is not able to be visualized adequately via the transinguinal approach without additional maneuvers and that up to 10% of PPV could be missed using a 70° scope when compared with the 120° scope.¹⁸ Using the transumbilical route has eliminated the inability to visualize the contralateral internal ring.

To date, there have been numerous techniques reported for closure of the internal ring. One concern that exists is the technical difficulties associated with the laparoscopic approach, specifically, concerns about longer operative times. The most recently published literature, including two randomized trials, would support that the actual operative times are not significantly longer than with the open approach and are potentially shorter. In a prospective trial that randomized patients based on the day of the week, the operative time favored the laparoscopic approach (25 minutes versus 31 minutes; P=.06).¹⁸ In a randomized trial comparing laparoscopic repair with open repair in 250 patients, the actual operative time for a unilateral laparoscopic repair was 8 minutes compared with 13 minutes (P<.005) for the open repair.¹⁵ In this same study, operative time for bilateral inguinal hernia repair also favored the laparoscopic approach (11 minutes versus 22 minutes; P<.005). In a more recent randomized trial comparing 62 male patients the laparoscopic repair was also found have a shorter operative time when compared with the open approach; however, this was not statistically significant.¹⁹ Based on the best available evidence, it appears that there is not a significant difference between the laparoscopic and open approaches.

Cosmesis is often reported as an advantage in MIS. This has also been reported for the MIS approach to inguinal hernia repair in children.^14,15 In the randomized trial in 62 males noted above, the parents of the patients were asked to score the wound appearance between the open and laparoscopic repairs. The only surgical scars that were deemed significantly superior were the laparoscopic scars in the bilateral inguinal hernia cohort compared against the open bilateral inguinal hernia repair. There was no difference in the comparison of all other groups.¹⁹ Others have subjectively reported that the tiny laparoscopic incisions are cosmetically superior to the open incisions, but also emphasized that any cosmetic benefit is likely to be minimal given the location of the open incision.^20,21 This point is highlighted by a recent report comparing the surgical scars after single-incision with those after three-port appendectomy. The ports in the three-port approach to appendectomy are placed in a location similar to the incision for an open inguinal hernia repair. This study found no significant difference in patient and parental scar assessment at a median of 25 months of follow-up.²² At present there is insufficient evidence to support that the laparoscopic inguinal hernia repair offers a relevant cosmetic advantage over the open technique.

As with most MIS approaches, postoperative pain after laparoscopic inguinal hernia repair has been reported to be less than that experienced after open repair. However, a recent randomized trial comparing laparoscopic and open repair was terminated early when interim analysis found that the laparoscopic approach required significantly more rescue analgesia in the recovery room than the open repair.²¹ Although there was a difference in need for rescue analgesia, there was no difference in the modified objective pain score in the recovery room or the primary outcome variable (return to normal activity) between the two groups. Another prospective trial found higher visual analog scale scores related to open repair when compared with the laparoscopic approach (6.8 versus 3.9; P<.05), whereas the other randomized trial found no difference in analgesic requirements between groups.^19,20 Based on these data, it appears that postoperative pain after inguinal hernia repair in children is not significantly affected by operative approach. However, as MIS approaches evolve, we should remain cognizant of postoperative pain, especially if the repair involves incorporation of a significant portion of the abdominal wall musculature.

Inguinal hernia repair, regardless of approach, is a safe procedure, with the most common complication being wound infection, testicular injury, and recurrence. Recurrence is discussed later in this review. Several studies have shown no increased risk associated with the laparoscopic repair, including overall complications, testicular blood flow, and volumes.^15,23,24 Protection of adjacent or incarcerated structures has also been reported. In a report by Kaya et al.,²⁵ laparoscopy allowed for direct visual control, examination of the incarcerated organ, and repair of the hernia in the same operative time. The authors suggested that the use of carbon dioxide insufflation allowed for expansion and excellent visualization of the internal inguinal ring, making identification of the nearby structures easy and leading to a decrease in complications that would be related to damage of the structures in the vicinity of the hernia during an open reduction and repair.²⁵

Recurrence

Recurrence is probably the most important consideration that leads surgeons to delay adoption of the laparoscopic approach. Recurrence rates have been subjectively criticized as being higher for the laparoscopic than the open approach. It results in parents' and patients' disappointment and raises concerns about potential lawsuits if the open repair is associated with lower rates.¹⁶

The data on recurrence are somewhat difficult to translate to the entire population owing to the variety of repairs that are being performed. However, the reported literature suggests that there is not a significant difference in recurrence rates between the laparoscopic and open repairs.

A retrospective report of 884 patients found a recurrence rate of 3%.¹⁶ Another review of 275 laparoscopic repairs identified four recurrences (1.5%) over a 2-year follow-up.²⁶ Smaller series with variable follow-up have reported 0%–3% recurrence rates.^11,14,27,28 Regarding prospective data, recurrence was seen in 0.8% of 125 patients undergoing laparoscopic repair compared with 2.4% of 125 patients undergoing open repair.¹⁵

The only reported meta-analysis identified three randomized trials and four observational studies totaling 1543 laparoscopic repair and 657 open repairs for comparison. The meta-analysis concluded that based on these reports, the recurrence rate is not different between laparoscopic and open herniorrhaphy.²⁹

Advancements and Improvements in the Repair

A review of all the technical approaches to MIS inguinal hernia repairs in the pediatric population is beyond the scope of this review. However, several unique approaches and investigations warrant mention.

Laparoscopic inguinal hernia repair has typically relied on using sutures to close the neck of the hernia sac, similar to how the open repair is performed. This approach has raised concern over the possibility of compromising the testicular vessels and other complications.³⁰ In order to avoid trauma to the cord structures, various investigational attempts at closing or obliterating the PPV have been reported. Fortunately, there is a reproducible animal model for these studies. All rabbits have a congenital PPV, which makes them an ideal model for investigation of PPV closure or obliteration.

One approach that has been proposed involves the use of polymeric gel. Kozlov et al.³⁰ have suggested using an injectable polymeric binding agent, DAM+™ (three-dimensional polyacrylamide gel with silver ions [Argiform^® from Bioform^®]), in this experimental model. DAM+ is a non-toxic, stable, nonresorbable sterile watery gel that is made of 2.5% cross-linked polyacrylamide and nonpyrogenic water. DAM+also contains silver, which reduces the risk for inflammation when used.³¹ DAM+ was injected into the PPV in 12 rabbits using a Tuohy needle. At the 6-month postmortem examination, there was no reopening of any of the PPV defects.

Another study reported the findings of five different tissue adhesives used to obliterate the PPV in rats, compared with a sham operation. The only tissue adhesive that successfully resulted in closure of the PPV as identified at the time of animal sacrifice was octylcyanoacrylate (Dermabond^®; Ethicon, Blue Ash, OH). The PPV was found to be patent in all animals where the four other tissue adhesives were used, as well as those undergoing sham operations. It is interesting that in this study fertility was assessed as sacrifice occurred after intercourse had led to conception of rat pups, and there was no difference in fertility between the octylcyanoacrylate-injected group and the sham operation group.³¹

A very important factor for durability of inguinal hernia repair likely involves some component of trauma to the peritoneum. This certainly occurs during the open repair where the sac is transected prior to ligation. In fact, it has been reported that the actual sac ligation may not be needed during repair, rather, just the sac transection.^32,33

This concept has been studied in the rabbit model. The durability of hernia sac ligation has been evaluated in combination with peritoneal trauma to initiate scarring. It is believed that the intentional peritoneal trauma, caused at the time of laparoscopic repair, may mimic the trauma inflicted during an open procedure (sac transection), which provides adequate scarring to close the internal ring.³⁴ This study compared suture ligation alone with suture ligation plus peritoneal trauma in 28 rabbits. The repairs were tested using pneumoperitoneum at 35 mm Hg after removal of the suture. All repairs with suture alone failed, whereas the suture plus trauma group showed 12.5% and 0% failure rates at 2 and 4 weeks, respectively, even after removal of the suture.

One issue that has come up in the past regarding the use of laparoscopic methods for pediatric hernia repair is the risk of injury to the vas deferens in the process of repairing an inguinal hernia.³⁵ Advances in laparoscopic hernia repair have looked at ways of limiting this risk and increasing the efficiency of the procedure for hernia repair. Hydrodissection has been reported as an aid in the dissection of the peritoneum off of the cord structures. In this technique, a single laparoscopic port is used, and the vas deferens and vessels are dissected from the peritoneal wall by infusing an isotonic saline solution into the peritoneal space through the vascular catheter. Although admittedly restricted because of having short-term follow-up of the patients in whom hydrodissection was used, there have been no recurrences, with reported limited trauma and damage to the vas deferens and vessels.³⁵

Finally, in an attempt to limit incarceration of muscle and nerve due to transabdominal wall ligation of the peritoneal at the internal ring, it has been suggested that the suture remain internal to the abdominal wall musculature. One report describes the use of a 17-gauge epidural needle, which is inserted through the lower half of the inguinal ring, over the testicular vessels, and pushing through the peritoneum. A nonabsorbable suture is pushed through the needle, with one end remaining above the skin allowing for the suture to be tied extracorporeally. The needle is then passed around the remainder of the ring, and the suture is passed back out the needle. Passing the suture through an epidural needle allowed for a minimization of complications caused by damage to nerves, muscles, and other tissues by the suturing process.³⁶

Conclusions

In spite of the advantages of laparoscopic approach that have been reported, there is still hesitation among pediatric surgeons to swiftly take on the procedure. However, based on the available literature, it appears that the laparoscopic approach to inguinal hernia repair in children is safe and effective with recurrence rates comparable to those for the open repair. There is no evidence to suggest increased complication rates or testicular risk. However, there are no large randomized trials comparing the two techniques. There is an opportunity for prospective comparison, which will require a multi-institutional effort.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Zani

, Eaton

, Hoellwarth

, et al. Management of pediatric inguinal hernias in the era of laparoscopy: Results of an international survey. Eur J Pediatr Surg, 2014; 24:9–13.

Lee

, Liang

. Experience with 450 cases of micro-laparoscopic herniotomy in infants and children. Pediatr Endosurg Innov Tech, 2002; 6:25–28.

Schier

, Montupet

, Esposito

. Laparoscopic inguinal herniorrhaphy in children: A three- center experience with 933 repairs. J Pediatr Surg, 2002; 37:395–397.

Schier

. Laparoscopic surgery of inguinal hernias in children—Initial experience. J Pediatr Surg, 2000; 35:1331–1335.

Lobe

, Schropp

. Inguinal hernias in pediatrics: Initial experience with laparoscopic inguinal exploration of asymptomatic contralateral side. J Laparoendosc Surg, 1992; 2:135–140.

Grosfeld

, Minnick

, Shedd

. Inguinal hernia in children: Factors affecting recurrence in 62 cases. J Pediatr Surg, 1991; 26:283–287.

Zendejas

, Zarroug

, Erben

, et al. Impact of childhood inguinal hernia repair in adulthood: 50 years of follow-up. J Am Coll Surg, 2010; 211:762–768.

Valusek

, Spilde

, Ostlie

, et al. Laparoscopic evaluation for contralateral patent processus vaginalis in children with unilateral inguinal hernia. J Laparoendosc Adv Surg Tech A, 2006; 16:650–653.

Draus

Jr , Kamel

, Seims

, et al. The role of laparoscopic evaluation to detect a contralateral defect at initial presentation for inguinal hernia repair. Am Surg, 2011; 77:1463–1466.

10.

Schier

. Laparoscopic herniarrhaphy in girls. J Pediatr Surg, 1998; 33:1495–1497.

11.

Takehara

, Yakabe

, Kameoka

. Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: Clinical outcome of 972 repairs done in 3 pediatric surgical institutions. J Pediatr Surg, 2006; 41:1999–2003.

12.

Montupet

, Esposito

. Laparoscopic treatment of congenital inguinal hernia in children. J Pediatr Surg, 1999; 34:420–423.

13.

Schier

, Gorsler

. Laparoscopic herniorrhaphy in children. Surg Endosc, 2003; 17:571–573.

14.

Parelkar

, Oak

, Gupta

, Sanghvi

, Shimoga

, Kaltari

, et al. Laparoscopic inguinal hernia repair in the pediatric age group—Experience with 437 children. J Pediatr Surg, 2010; 45:789–782.

15.

Shalaby

, Ibrahem

, Shahin

, Yehya

, Abdralrazek

, Alsayaad

, Shouker

. Laparoscopic hernia repair versus open herniotomy in children: A controlled randomized study. Minim Invasive Surg, 2012; 2012:484135.

16.

Schier

. The laparoscopic spectrum of inguinal hernias and their recurrences. Pediatr Surg Int, 2007; 23:1209–1213.

17.

Mollen

, Kane

. Inguinal hernia: What have we learned from the laparoscopic evaluation of the contralateral side. Curr Opin Pediatr, 2007; 19:344–348.

18.

Tamaddon

, Phillips

, Nakayam

. Laparoscopic evaluation of the contralateral groin in pediatric inguinal hernia patients: A comparison of 70- and 120-degree endoscopes. J Laparoendosc Adv Surg Tech A, 2005; 15:653–660.

19.

Celebi

, Uysal

, Inal

, et al. A single-blinded, randomized comparison of laparoscopic versus open bilateral hernia repair in boys. J Laparoendosc Adv Surg Tech A, 2013 Nov 28 [Epub ahead of print]. doi: 10.1089/lap/2013.0397.

20.

Saranga Bharathi

, Avora

, Baskaran

. Pediatric inguinal hernia: Laparoscopy versus open surgery. JSLS, 2008; 12:277–281.

21.

Koivusalo

, Korpela

, Wirtavuori

, et al. A single-blinded, randomized comparison of laparoscopic versus open hernia repair in children. Pediatrics, 2009; 123:332–337.

22.

Gasior

, Knott

, Holcomb

3rd , et al. Patient and parental scar assessment after single incision versus standard 3-port laparoscopic appendectomy: Long-term follow-up from a prospective randomized trial. J Pediatr Surg, 2014; 49:120–122.

23.

Saka

, Okuyama

, Sasaki

, et al. Safety and efficacy of laparoscopic percutaneous extraperitoneal closure for inguinal hernias and hydroceles in children: A comparison with traditional open repair. J Laparoendosc Adv Surg Tech A, 2014; 24:55–58.

24.

Çelebi

, Yıldız

, Üçgül

, et al. Do open repair and different laparoscopic techniques in pediatric inguinal hernia repairs affect the vascularization of testes?. J Pediatr Surg, 2012; 47:1706–1710.

25.

Kaya

, Hückstedt

, Schier

. Laparoscopic approach to incarcerated inguinal hernia in children. J Pediatr Surg, 2006; 41:567–569.

26.

Dutta

, Albanese

. Transcutaneous laparoscopic hernia repair in children: A prospective review of 275 hernia repairs with minimum 2-year follow-up. Surg Endosc, 2009; 23:103–107.

27.

Shah

, Arlikar

, Dhende

. Incise, dissect, excise and suture technique of laparoscopic repair of pediatric male inguinal hernia. J Minim Access Surg, 2013; 9:72–75.

28.

Kumar

, Ramakrishnan

. Single port laparoscopic repair of pediatric inguinal hernias: Our experience at a secondary care center. J Minim Access Surg, 2013; 9:7–12.

29.

Yang

, Zhang

, Pu

, Mei

, Zheng

, Tong

. Laparoscopic vs open herniorrhaphy in the management of pediatric inguinal hernia: A systemic review and meta-analysis. J Pediatr Surg, 2011; 46:1824–1834.

30.

Kozlov

, Novogilov

, Rasputin

, Podkamenev

, Krasnov

, Weber

, Solovjev

. Laparoscopic inguinal preperitoneal injection—Novel technique for inguinal hernia repair: Preliminary results of experimental study. J Laparoendosc Adv Surg Tech A, 2012; 22:276–279.

31.

Kato

, Yamataka

, Miyano

, et al. Tissue adhesives for repairing inguinal hernia: A preliminary study. J Laparoendosc Adv Surg Tech A, 2005; 15:424–428.

32.

Tabrizian

, Raisolsadat

, Houshmand

, et al. Assessment of the necessity of sac high ligation in inguinal hernia open surgery among children. J Pediatr Surg, 2013; 48:547–549.

33.

Riquelme

, Aranda

, Riquelme-Q

. Laparoscopic pediatric inguinal hernia repair: No ligation, just resection. J Laparoendosc Adv Surg Tech A, 2010; 20:77–80.

34.

Blatnik

, Harth

, Krpata

, Kelly

, Schomisch

, Ponsky

. Stitch versus scar—Evaluation of laparoscopic pediatric inguinal hernia repair: A pilot study in a rabbit model. J Laparoendosc Adv Surg Tech, 2012; 22:848–851.

35.

Chang

, Lin

, Tsai

, Chiu

. Comparative mid-term results between inguinal herniotomy and single-port laparoscopic herniorrhaphy for pediatric inguinal hernia. Surg Laparosc Endosc Percutan Tech, 2012; 22:526–531.

36.

Tatekawa

. Laparoscopic extracorporeal ligation of hernia defects using an epidural needle and preperitoneal hydrodissection. J Endourol, 2012; 6:474–477.