Fifteen Years Experience with Laparoscopic Inguinal Hernia Repair in Infants and Children

Abstract

Background:

Laparoscopic inguinal hernia repair (LIHR) is gaining popularity with more studies validating its feasibility, safety, and efficacy. The aim of this work is to review our experience with LIHR in infants and children during the past 15 years, and present and evaluate our innovations of laparoscopic techniques.

Patients and Methods:

A retrospective study of 1284 patients with congenital inguinal hernia (CIH) subjected to different techniques of LIHR from October 2000 to October 2015. The main outcome measurements included the following: operative time, hospital stay, hernia recurrence, hydrocele formation, testicular atrophy, iatrogenic ascent of the testis, and cosmetic results.

Inclusion Criteria:

All patients with CIH who were managed by LIHR during the period of study. They were bilateral cases, recurrent hernias, unilateral hernia in obese child, unilateral hernia with associated infantile umbilical hernia, and unilateral hernia with questionable contralateral side.

Results:

A total of 1284 patients with CIH were corrected with different laparoscopic procedures. They were 918 males and 366 females. The age range was variable from 6 to 78 months (mean 28.32 ± 24.46 months). All cases were completed laparoscopically without major intraoperative complications. Contralateral hernial defects were found in 294 patients (22.90%), a direct inguinal hernia (IH) was discovered in 15 patients (1.17%), and a femoral hernia was discovered in 3 patients (0.23%). Recurrence occurred in 9 boys (0.98%) who were among the early cases; however, in later group, no recurrence had been detected. Hydrocele occurred in 19 cases (males) (2.07%), without detection of testicular atrophy or iatrogenic ascent of the testis.

Conclusion:

Our results lead us to believe that LIHR by expert hands is safe and effective. It enables the surgeon to discover and repair contralateral hernia and all forms of IHs. One should be able to tailor a suitable technique for each case according to the resources and expertise.

Introduction

Congenital inguinal hernia (CIH) is common in pediatric age group. Open herniotomy is the optimum standard for its treatment. Over the last two decades, minimally invasive surgery has challenged conventional surgery regarding the cosmetic results and early recovery.^1,2 Advantages of laparoscopic inguinal hernia repair (LIHR) include the following: excellent visual exposure, the ability to evaluate the contralateral side, avoids trauma to the vas, vessels, or bladder, avoids iatrogenic ascent of the testis, extensive dissection of spermatic vessels and vas deferens, and is helpful in detecting other rare hernias as direct hernias, femoral hernias, and pantaloon hernias with excellent cosmetic results²

Different laparoscopic approaches have been devised and later advanced for management of inguinal hernia (IH) in pediatrics. Three-port laparoscopic approach (with either ligation of hernia defect leaving hernia sac intact or disconnection of the hernia sac) was associated with increased operative time, cost, and postoperative pain.^1,2 Recently, LIHR has progressed rapidly from three to two ports, and now single-incision pediatric endoscopic surgery is widely used.^3,4 It has the potential to provide a better and more desirable cosmetic outcome in addition to less operative time and postoperative pain.^5–7

Congenital IH repair using percutaneous extracorporeal internal inguinal ring (IIR) suturing is an effective alternative approach to conventional LIHR. It is one of the most commonly used techniques for LIHR. It has been described that LIHR with extracorporeal ligation, compared with intracorporeal suturing, resulted in a marked reduction in operative time, low comparative recurrence rates, and excellent cosmetic results.⁸ Nevertheless, most described techniques use extracorporeal ligation of the suture with burying the knot subcutaneously. This may result in infection, granuloma, stitch sinus, and puckering of the skin. Furthermore, the inclusion of muscular tissues with the suture leads to increased rate of recurrence due to cut through the muscular tissues and loosening of the suture.^9,10 All these drawbacks can be avoided by applying intracorporeal knotting and burying the knot intra-abdominally and not subcutaneously.^11,12

We applied all techniques of LIHR along the past 15 years namely three-trocar intracorporeal LIHR with transperitoneal ligation of the hernial sac at the IIR leaving the sac intact, or after its disconnection, two-trocar laparoscopic extracorporeal percutaneous suturing of IIR technique, using Reverden needle (RN), single-incision laparoscopic-assisted percutaneous pediatric IH repair using RN (Shalaby technique),¹³ and recently, we invented and applied one-trocar needlescopic-assisted hernia repair after partial cauterization of the upper half of the hernia sac at IIR away from the vas and vessels. The addition of cauterization of the upper half of the hernia sac at IIR led to sound healing and prevented recurrence. Burying the knot intraperitoneally resulted in avoidance of the drawbacks of its presence in the subcutaneous tissue. The main concept of this technique was the percutaneous insertion of purse-string suture around the IIR using epidural needle (EN), venous access cannula (VAC), and a simple homemade suture retriever device (SRD) with extracorporeal suture tying and intra-abdominal burying of the knot. The aim of this work is to review our experience with LIHR in infants and children during the past 15 years, and present and evaluate our innovations of laparoscopic techniques.

Patients and Methods

This is a retrospective study of 1284 patients with IH corrected laparoscopically along the period from October 2000 to October 2015. Inclusion criterion: all patients with IH who were managed by LIHR during the period of study. They were bilateral cases, recurrent hernias, unilateral hernia in obese child, unilateral hernia with associated infantile umbilical hernia, and unilateral hernia with questionable contralateral side. Data regarding the age, sex, type of hernia, its description, and different laparoscopic techniques applied were collected. The main outcome measurements included the following: operative time, hospital stay, hernia recurrence, hydrocele formation, testicular atrophy, iatrogenic ascent of the testis, and cosmetic results. Collection of data was obtained from archives, previous studies, and direct contact with the patients. The details of the techniques are described elsewhere.^13,14

Ethical Consideration

The protocol was discussed and approved for clinical study by the Ethics Research Committee of Al-Azhar University and other centers.

Results

A total of 1284 patients with 1689 hernial defects were corrected laparoscopically at Mashary Hospital [Ryad, Saudi Arabia], Al-Azhar, Mansoura University Hospitals, and some private hospitals along the period of the study from October 2000 to October 2015. The reports of these patients were collected and analyzed. They were 918 boys and 366 girls. Laparoscopic findings were recorded; contralateral hernial defects were found in 294 patients (22.90%), for which bilateral LIHR was done. In 15 patients (1.17%), a direct IH was reported and femoral hernia was discovered in 3 patients (0.23%). All cases were completed laparoscopically without major intraoperative complications. The demographic data and the laparoscopic findings of all patients are shown in Table 1.

Table 1.

The Demographic Data and Laparoscopic Findings of All Patients

Demographic data
Age		Sex, n (%)
Mean	28.32 ± 24.46	Male	918 (71.50)
Range	6 to 78 months	Female	366 (28.50)

Prelaparoscopy clinical data		Laparoscopic findings
Type of hernia	No. of patients	Type of hernia	No. of defects
Right CIH	718 patients	Right CIH	718
Right CIH	718 patients	Left contralateral CIH	160
Left CIH	342 patients	Left CIH	342
Left CIH	342 patients	Right contralateral CIH	134
Bilateral CIH	111 patients	Bilateral CIH	222
Right recurrent CIH	70 patients	Right recurrent CIH	60
Right recurrent CIH	70 patients	Right direct CIH	10
Left recurrent CIH	43 patients	Left recurrent CIH	35
		Left direct CIH	5
		Left femoral	3
Total	1284 patients		1689 defects

CIH, congenital inguinal hernia.

Five different laparoscopic techniques were applied to the patients included in our study: (1) three-trocar laparoscopic intracorporeal purse-string suture technique in 410 cases (305 males and 105 females) with 644 hernia defects. In 2 cases, stress test was positive and a second suture was inserted again around the IIR. Hydrocele developed in 4 patients. There were 8 cases of recurrence in boys and no recurrence in girls. (2) Three-trocar laparoscopic intracorporeal disconnection and ligation of the hernia sac technique in 113 males with 154 hernia defects. Intraoperative bleeding (hematoma) occurred in 2 cases, which was controlled by external compression at the groin area. Postoperative hydrocele developed in 7 cases, which was resolved spontaneously within 2 months. No recurrence was reported in this technique and no testicular atrophy or iatrogenic ascent of the testis was reported during the period of follow-up. (3) Two-trocar laparoscopic extracorporeal percutaneous RN suturing of IIR technique in 334 cases (193 males and 141 females) with 420 hernia defects. There were 2 cases of intraoperative bleeding (hematoma), which was controlled by external compression at the groin area. Postoperative hydrocele developed in 4 cases, which resolved spontaneously within 3 weeks and no recurrence was reported. (4) Single-incision laparoscopic-assisted percutaneous technique (Shalaby technique, RN) in 150 cases (101 males and 49 females) with 170 hernia defects. On follow-up, there was only 1 case of recurrence in a boy and 2 cases developed hydrocele that resolved spontaneously within 3 weeks. (5) One trocar needlescopic-assisted percutaneous technique in 277 cases (206 males and 71 females) with 301 hernia defects. Hematoma occurred in 3 cases due to an inadvertent injury of inferior epigastric vessels, which were managed by deflation of the abdomen and applying continuous pressure on the anterior abdominal wall at the region of IIR for 5 minutes. In 4 cases, there was a wide skip area during insertion of purse-string suture that necessitated reinsertion of a second one around the IIR. In 4 male patients with redundancy of peritoneum at the IIR, a blunt homemade fine probe was inserted through VAC to assist in stretching the peritoneum around the IIR during purse-string suturing. On follow-up, there were only 2 cases of hydrocele without any recurrence or testicular atrophy. The details of different laparoscopic findings and techniques are summarized in Table 2.

Table 2.

Different Laparoscopic Findings and Techniques Procedures

Procedures	Three-trocars
Items	Purse string	Disconnection	Two-trocar RN	Single incision (Shalaby technique)	OTNAHR	Total
Patients, n	410	113	334	150	277	1284
Defect, n	644	154	420	170	301	1689
Mean age	28.61 ± 27.46	23.87 ± 24.81	24.63 ± 22.09	25.59 ± 18.94	34.54 ± 24.34	28.32 ± 24.46
Male	305	113	193	101	206	918 (71.5%)
Female	105	0	141	49	71	366 (28.5%)
Right sided	175	72	206	93	172	718
Left sided	95	18	102	37	90	342
Bilateral hernia	40	10	26	20	15	111
Recurrent hernia	100	13	0	0	0	113
Laparoscopic finding of hernial defects for different techniques
Right sided	175	72	206	93	172	718
Left sided	95	18	102	37	90	342
Bilateral hernia	80	20	52	40	30	222
Recurrent hernia	88	7	0	0	0	95
Contralateral hernia	194	31	60	0	9	294
Direct hernia	9	6	0	0	0	15
Femoral hernia	3	0	0	0	0	3
OT/unilateral (minutes)	15 ± 2.27	27.67 ± 2.77	8.7 ± 1.72	12.4 ± 1.66	12.60 ± 1.40	13.31 ± 5.29
OT/bilateral (minutes)	20 ± 1.99	32 ± 3.2	12.35 ± 1.73	18.6 ± 1.76	18.6 ± 1.88	19.50 ± 5.38
Bleeding	0	2	2	0	3	7 (0.54%)
Hydrocele (boys)	4	7	4	2	2	19 (2.07%)
Recurrence (boys)	8	0	0	1	0	9 (0.98%)
Stress test	2	0	0	0	0	2 (0.15%)
Skip area	0	0	0	0	4	4 (0.31%)
Blunt probe	0	0	0	0	4	4 (0.31%)

OTNAHR, one trocar needlescopic assisted hernia repair; RN, Reverden needle.

All cases were completed laparoscopically without conversion. All patients had minimal postoperative discomfort and resumed normal activities later on the same day of surgery. The mean hospital stay was 7.79 ± 1.28 hours (range 5–19 hours) and 10% of children stayed one night postoperatively when living far away from the hospital or at parental request. Patients were seen 7 days, 2 weeks, 6 months, and 1 year later.

The overall results were acceptable; there were 19 cases (males) of hydrocele (2.07%), 2 required percutaneous aspiration, while the others resolved spontaneously. We recorded only 9 recurrences (0.98%) in boys, which had occurred in early cases of the study, and no recurrence in girls. All recurrent cases were reoperated by laparoscopy. There were no cases of postoperative testicular atrophy or testicular malposition in our series, and the cosmetic results were excellent.

Discussion

In this study, we present our experience with LIHR in infants and children along the past 15 years, aiming to assess the application of different techniques for LIHR and to present our novel techniques as well.^11,13

Open IH repair is an excellent method of management of CIH in pediatrics and is considered the gold standard by many surgeons today. However, it has the minimal potential risk of injury of the spermatic vessels and vas deferens, hematoma formation, wound infection, iatrogenic ascent of the testis, testicular atrophy, and recurrence.¹⁵ The standard surgical maneuver for CIH is high ligation of the hernia sac without narrowing the ring.¹ Recently, the literature contains lots of reports on LIHR in children, highlighting an increase not only in the number of cases managed but also the number of modifications and technical refinements of the procedure itself.¹⁰ The laparoscopic techniques are rapidly gaining popularity over the open approach.¹⁶ Laparoscopic IH repair comes upon the hernia at the site of origin, leaving the outer anterior abdominal wall intact. It also avoids dissection of spermatic vessels and vas deferens, and detects other pathology and other hernias as contralateral, direct, femoral, and pantaloon hernias with excellent cosmetic results.²

There are two main LIHR techniques (intracorporeal and extracorporeal). All intracorporeal techniques involve a total laparoscopic approach for obliterating the IIR. Typically, these repairs necessitate the placement of a minimum of three trocars: one for camera and two for working instruments. The desire of pediatric surgeons to reduce the morbidity rate and scar existence has stimulated the application of less invasive techniques. However, it is challenging, especially during suturing and knot tying.^17,18 Single-incision LIHR is an evolving technique that reduced multiple skin incisions and improved cosmoses.^19,20 Extracorporeal percutaneous techniques involve the placement of a suture circumferentially around the IIR and tying the knot extracorporeally with burying the knot subcutaneously.¹⁷

Hydrocele is a well-known complication of LIHR, the reasons for which can be explained by loose ligation of the sac in continuity or by leaving a small skip area over the vas and vessels, which act like a one-way valve, or taking additional tissue in the purse-string suture around the peritoneum with inclusion of the lymphatics.²¹ In our series, we had hydrocele formation in 19 male cases (2.07%), which are accepted in comparison to others.^8,20,22

Laparoscopic IH holds a higher recurrence rate compared to the traditional open technique, ranging from 0.83% to 4.1%.^17,21,22 The reasons include the following: failure to ligate the hernia sac high enough at the IIR, tension at the closure of the internal opening, wide hernia defect, broken purse-string thread, presence of skip area especially over the vas and spermatic vessels, the suture technical problems, hematoma formation at the open wound, and laparoscopic surgeon with limited experience. A recurrence will not occur if the purse-string knot is confirmed with the stress test by an increase in the intraperitoneal CO₂ pressure at the end of the operation.²¹ In our study, recurrence occurred in 9 boys (0.98%), which is comparable to that obtained with open repair and lower than that obtained with others performing LIHR.^15,23,24 All operations were done by the first four authors who have an extended experience with different laparoscopic techniques, especially LIHR, and this explains our very low recurrence rate.

Laparoscopic hernia repairs are not more time-consuming. However, it may take longer operative time than open herniotomy, especially in the early stages of learning curve and in some intracorporeal techniques like disconnection of the sac. Many reports show that it ranged from 25 to 74 minutes.^25–27 However, a longer operative time was reported by Tsai et al., who stated that the mean operation time was 52 minutes (range = 22–109 minutes) with the duration decreasing with experience.²⁸ Other studies stated that the laparoscopic group had a shorter mean operative time for bilateral herniorrhaphies than the open group.^29–31 It is well known that the operative time depends on the operative technique used and the stage of learning curve as the operative time of laparoscopic percutaneous extraperitoneal closure for IH in children is comparable to the time needed for a conventional open repair or even less.^{1,21,22,32,33}

Intracorporeal laparoscopic hernia repair with dissection of the hernial sac may take a longer operative time, even more than open herniotomy.²⁹ Riquelme et al. reported that the operative time ranged from 35 to 72 minutes.²⁵ Schier stated that open herniotomy may be slightly quicker than laparoscopy in girls with a unilateral hernia.²⁴ In a more recent randomized trial, Celebi et al. stated that although the operative time for laparoscopic hernia repair was slightly shorter, there was no statistically significant difference in operative time to repair the bilateral hernias between the two groups.³⁴ Ponsky et al. mentioned that based on the best available evidence, it appears that there is no significant difference between the laparoscopic and open approaches.⁷ The operative time is reduced gradually with advancing learning curve.^20,22 The operative time was significantly longer in the unilateral LIHR and there was a trend toward shorter operative time in favor of laparoscopic bilateral IH repair.^3,22,35

In our study, the operative time depended on the technique used and generally, it is lower than that reported in the literatures because LIHR was started after gaining good experiences in different laparoscopic procedures.

In all our techniques for LIHR, we applied strict technical rules and refinements to improve our results such as injecting normal saline into the extraperitoneal space at IIR, including subperitoneal tissue all around IIR, emphasis on applying “complete ring” sign, reducing tension on the knot of purse-string suture by deflation of the abdomen and squeezing the scrotum to empty the hernia sac while tightening, and the use of nonabsorbable suture.

Recently we used an easy, safe, simple, and rapid technique for repair of CIH using one-trocar needlescopic-assisted IH repair using only VAC, EN, and homemade suture retriever. The addition of cauterization of the upper half of the hernia sac at the level of IIR (as a sort of disconnection of the sac mimicking what is happening in open herniotomy) resulted in sound healing and decreased recurrence to 0%, and a fantastic cosmetic result. This procedure was devised by the first author and other authors followed the lead; his technique is currently being processed for publication.

Our latest technical refinements and modifications of the techniques resulted in reduced operative time, lowering the recurrence hernia to 0%, and marked reduction of development of postoperative hydrocele. Moreover, the cosmetic result is outstanding.

Footnotes

Disclosure Statement

No competing financial interests exist.

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