Laparoscopic Pediatric Inguinal Hernia Repair Using Purse-String Suture: Technical Recommendations After 20 Years Experience

Dear Editor:

We read with interest Dr. Steven's article titled: “Simple Purse String Laparoscopic Versus Open Hernia Repair” published in February 2016 of Journal of Laparoendoscopic & Advanced Surgical Techniques.

We congratulate the authors for their excellent work, but we would like to clarify some technical aspects of the simple purse-string technique to repair pediatric inguinal hernia, the technique that was described more than 20 years ago by Philippe Montupet.

After the first description of Montupet in 1993, ¹ when the defect was closed by performing a simple purse-string suture on the periorificial peritoneum at the level of internal inguinal ring, thanks to the teamwork of Montupet, Esposito, and Schier, ² the technique of simple purse-string suture was modified throughout the years to reduce the incidence of recurrence, which at the beginning of the experience was about 3%.

With a follow-up longer than 20 years, the authors have modified the technique in some important steps.

First of all, Montupet and Esposito published an article in 1999 on Journal of Pediatric Surgery, in which they modified two important aspects of the technique ³ : the first one is that before closing the defect, it is fundamental to section the periorificial peritoneum around the internal inguinal ring, the second one is that they prefer to use nonabsorbable suture to repair hernia defect. In this way they reported a near 0% recurrence rate.

These authors noted that if the inguinal orifice is very large, greater than 10 mm in diameter, if a simple purse-string suture is performed, there is too much tension on the suture and there is an important risk of recurrence, for this reason, to section the periorificial peritoneum, there is the collapse of the distal part of the sac and there is no tension in closing the purse-string suture.

If the defect is smaller than 5 mm in diameter, after sectioning the periorificial peritoneum, the defect can be closed either with a purse-string suture or with an N-shaped suture.

To our mind, the simple purse-string laparoscopic herniorrhaphy (LH) repair, as described by Steven et al., reported a too high recurrence rate (2.9%), whereas we reported with a 20 years follow-up using our technique a near 0% recurrence rate. We have no complications related to the dissection phase, above all because, thanks to the magnified view of surgical field on the screen, we avoided to touch the vas and the vessels that are so small in patients under 1 year of age.

The opening of the periorificial peritoneum with the use of monopolar coagulation is a technical detail similar to the peritoneal injury created at the internal inguinal ring described by Ostlie and Ponsky in their current technique. ⁴ We agree with these authors that this technical expedient does result in a more durable repair. Another important recommendation to avoid recurrences is to close well the medial part of the defect with the purse-string suture, which in our mind is the weakest point for recurrence after LH repair.

As for technical point of view, another important point of the technique is to adopt 3-mm screw trocars; in this way a truly mini-invasive procedure is performed and the trocars remain stable during the entire procedure, in particular during the change of instruments, and this aspect is very important in newborns and in general in patients under 1 year of age.

As for operative time, Steven et al. reported a significantly longer operative time in the LH group than in the open herniorrhaphy (OH) group, either for monolateral repair or for bilateral repair. In a recent systematic review, we reported that with regard to operative time, there was no significant difference between LH and OH in unilateral inguinal hernia repair. In contrast, in bilateral disease, LH is faster than OH. ⁵ Probably, this is also related to the learning curve. ⁶

The authors reported a total complication rate of 9.9% in the open repair group, with no difference compared with the LH group. We believe, in accordance with the international literature, that the incidence of some complications such as testicular atrophy or testicular ascent, after inguinal open exploration, is probably underestimated, especially because the follow-up of a patient who has undergone surgery for an inguinal hernia is rather short, whereas these complications occur much later and may be casually detected during adolescence.

In conclusion, on the basis of our 20 years experience, we believe that laparoscopic inguinal hernia repair is a safe and effective procedure in children and neonates. In addition, its ability to repair also the rare forms of inguinal hernia together with contralateral patency has further cemented its role as a preferable alternative to the conventional inguinal approach. ⁷ We suggest that the technique, refined and standardized by Montupet in the 1990s, should be considered the gold standard among intracorporeal repair methods, for correction of pediatric inguinal hernia through laparoscopy.