Abstract
Introduction:
“Hernia en pantalon” is a combination of indirect and direct inguinal hernias, which, according to the up-to-date literature, has rarely been reported in children. 1,2 In fact, before introduction of routine laparoscopy for inguinal hernia repair, these particular forms of combined inguinal hernias were unknown in children. 3,4 We report our experience with laparoscopic treatment of hernia en pantalon in children.
Materials and Methods:
In a 20-year period (1997–2017), 1320 infants and children underwent laparoscopic inguinal hernia repair. Preoperatively all patients presented a monolateral inguinal hernia, located either on the right side, in 791 cases (60.1%), or on the left side, in 529 cases (39.9%). In 6/1320 cases (0.5%), a double hernia (direct + indirect) on the same side (hernia en pantalon) was found intraoperatively. We adopted a 5- or 10-mm umbilical trocar for the 0° 5- or 10-mm optic and two 3-mm screw trocars for the instruments. Pneumoperitoneum pressure varied between 8 and 12 mm Hg. The diagnosis of the hernia en pantalon was made intraoperatively. In dealing with indirect hernia defect, after section of the periorificial peritoneum with the monopolar hook, the hernia orifice was closed with a purse-string suture (Montupet's technique) using nonresorbable suture and a transparietally introduced 3/8 circle needle of 22 mm length. All direct hernia defects were >10 mm and in each case a big lipoma adherent to the hernia sac was found. After the lipoma resection using the hook cautery, the direct hernia defect was closed with either a purse-string suture (Montupet's technique) or an N-shaped suture (Schier's technique). Moreover, the closure was reinforced with interrupted stitches or, in some cases, using the vesical ligament. Finally, the contralateral patency of the peritoneovaginal duct was always checked and if present it was repaired accordingly. Written informed consent was obtained from all subjects participating in the study.
Results and Conclusions:
All procedures were completed in laparoscopy without conversions to open surgery. Average operative time was 28.7 minutes [range 21–48]. No intraoperative nor postoperative complications were reported. All the procedures were performed in a day-hospital setting with an overnight hospitalization. At the longest follow-up of 5 years, no recurrence was recorded and cosmetic result was excellent in all patients. With the routine use of laparoscopy, the so called rare hernias are more easily and often identified and all hernia forms—indirect, direct, femoral, and hernias en pantalon—can be treated using a uniform and standardized approach. 1,5,6 Our technical recommendation is first of all to empty the bladder before surgery to prevent the full bladder from covering a medial defect as direct or femoral hernias. 7 In all direct hernias, the reduction of the associated lipoma into the abdominal cavity and its resection is fundamental to avoid hernia recurrence. 6,7 Considering that direct defects, as happened in our series, are often >10 mm, to avoid tension on the defect's borders after closure, the vesical ligament may be adopted to reinforce the closure. 7
No competing financial interests exist.
Runtime of video: 2 mins 29 secs
