Laparoscopic inguinal hernia repair in premature babies weighing 3 kg or less

European Pediatric Surgeons' Association Survey on Timing of Inguinal Hernia Repair in Premature Infants

AIM

 This article evaluates the practice patterns of European Pediatric Surgeons' Association (EUPSA) members regarding the timing of inguinal hernia (IH) repair in premature infants.

METHODS

 Online survey containing 29 questions distributed to EUPSA members during January 2023.

RESULTS

 A total of 180 responds were received. Overall, IH repair prior to discharge was favored by 60% of respondents when there was a history of incarceration and 56% when there was not. In the case of very/extremely premature infants (< 32 weeks) with no history of incarceration, fewer (43%) respondents postpone the surgery until after discharge. The majority of respondents cited the risk of incarceration as the reason for advocating surgery prior to discharge, whereas a reduced risk of apnea was the most cited reason for respondents who prefer delayed surgery. Open approach under general anesthesia was favored by 54% of respondents, with 27% of them preferring open approach with spinal anesthesia. Laparoscopic surgery for premature infants is used in 11% while 7% of them preferred in all premature infants including extremely/very premature ones. Contralateral side evaluation was never done by 40% of respondents and 29% only performed it only during laparoscopic repair. The majority of respondents (77%) indicated that they have an overnight stay policy for premature infants < 45 weeks of gestation.

CONCLUSION

 There is variation in the practice patterns of pediatric surgeons in the treatment of IH in premature infants. Due to the concern for the high risk of incarceration, IH repair before discharge was the most prevalent practice. Lower risk of postoperative apnea was cited as the most common reason for delaying surgery. Randomized studies are required to establish the optimal timing for IH repair in premature infants.

Wound cosmesis problems and other postoperative problems of laparoscopic compared to open paediatric inguinal hernia repair: A meta-analysis

A meta-analysis research was executed to appraise the wound cosmesis problems and other postoperative problems of laparoscopic compared to open paediatric inguinal hernia (IH) repair. Inclusive literature research until March 2023 was done and 869 interconnected researches were revised. The 11 picked researches enclosed 3718 paediatric inguinal hernia were in the utilised researches' starting point, 1948 of them were utilising laparoscopic IH repairs, and 1770 were utilising open IH repairs. Odds ratios (ORs) in addition to 95% confidence intervals (CIs) were utilised to appraise the wound cosmesis problems and other postoperative problems of laparoscopic compared to open paediatric IH repairs by dichotomous approaches and a fixed or random model. Laparoscopic IH repairs had significantly lower wound cosmesis problems (OR, 0.29; 95% CI, 0.16-0.52, P < .001), metachronous contralateral inguinal hernia (MCIH) (OR, 0.11; 95% CI, 0.03-0.49, P = .003), recurrence (OR, 0.34; 95% CI, 0.34-0.99, P = .04) and postoperative problems (OR, 0.35; 95% CI, 0.17-0.73, P = .005), and higher wound score (OR, 12.80; 95% CI, 10.09-15.51, P < .001) compared to open paediatric IH. Laparoscopic IH repairs had significantly lower wound cosmesis problems, MCIH, recurrence, and postoperative problems, and a higher wound score compared to open paediatric IH. However, when interacting with its values, caution must be taken since much of the research had low sample sizes.

Laparoscopic hernia repair in children: does recreating the open operation improve outcomes? A systematic review

PURPOSE

The use of laparoscopy for paediatric inguinal hernia repairs has increased significantly over the past 2 decades. However, there is significant variation in the reported recurrence rates in the literature, with many studies reporting higher rates than the open operation. This may be explained by the range of different techniques currently included under the term laparoscopic inguinal hernia repair. The purpose of this study is to determine whether dividing the hernia sac before ligation improves surgical outcomes following a paediatric laparoscopic inguinal hernia repair compared to ligation alone.

METHODS

A systematic review of the literature was performed following PRISMA guidelines of all studies reporting the outcomes following paediatric laparoscopic inguinal hernia repair where the technique was recorded as laparoscopic suture ligation alone (LS) or laparoscopic sac division and suture ligation (LSDS). Studies were assessed for risk of bias and exclusion criteria included reported follow-up of less than 6 months.

RESULTS

A total of 8518 LS repairs and 6272 LSDS repairs were included in the final analysis. LSDS repair was associated with a significantly lower recurrence rate (odds ratio 0.51, 95% CI 0.36-0.71, p = 0.001). There was no significant difference in the rates of testicular ascent or atrophy.

CONCLUSION

Recreating the open operation by hernia sac division followed by suture ligation significantly reduces the risk of hernia recurrence.

Comparing Outcomes of Single-Incision Laparoscopic Herniorrhaphy in Newborns and Infants

BACKGROUND

As surgical techniques progress, laparoscopic herniorrhaphy is now performed more often in premature babies. The aim of this study was to analyze the outcomes of newborns and infants who underwent single-incision laparoscopic herniorrhaphy (SILH) at our center.

METHODS

We retrospectively reviewed patients younger than 12 months old who received SILH at our department from 2016 to 2020. SILH involved a 5 mm 30-degree scope and 3 mm instruments with a 3-0 Silk purse-string intracorporeal suture for closure of the internal ring. At the time of surgery, Group 1 newborns, whose corrected age was 2 months and below, were compared to the Group 2 infants, whose age was above 2 months. We assessed the patients' characteristics, anesthesia, surgical data, and complications.

RESULTS

A total of 197 patients were included (114 newborns in Group 1 and 83 infants in Group 2). The mean age and body weight in Group 1 were 1.2 months and 3.8 kg, respectively, whereas in Group 2, they were 3.2 months and 6.7 kg, respectively. There were no significant differences in operative time (Group 1 = 34.1 min vs. Group 2 = 32.3 min, p = 0.26), anesthetic time (Group 1 = 80.0 min vs. Group 2 = 76.3 min, p = 0.07), length of hospitalization (Group 1 = 2.3 days vs. Group 2 = 2.4 days, p = 0.88), postoperative complications including omphalitis (Group 1 = 5.3% vs. Group 2 = 1.2%, p = 0.13), wound infection (Group 1 = 0.9% vs. Group 2 = 1.2%, p = 0.81), and hydrocele (Group 1 = 0.35% vs. Group 2 = 8.4%, p = 0.14). No recurrence, testicular ascent or atrophy, or mortality was observed in either group during the 2-year follow-up period.

CONCLUSIONS

Single-incision laparoscopic herniorrhaphy is a safe and effective operation for inguinal hernia repair in infants, even those with prematurity, lower body weight at the time of surgery, or cardiac and/or pulmonary comorbidities. Comparable results revealed no significant differences in perioperative complications despite younger ages and lower body weights.

A comparison of operative and anesthetic techniques for inguinal hernia repair in infants

BACKGROUND

Pediatric inguinal hernia repair (IHR) is increasingly performed using minimally invasive surgery (MIS) but has only recently been described using caudal block without endotracheal intubation. We evaluated the surgical outcomes and resource utilization of infants undergoing hernia repair, comparing both the operative approach (open/MIS) and anesthetic technique (general anesthesia [GA]/caudal).

METHODS

All infants <1 year-of-age undergoing elective IHR without concomitant procedures from July 2016 to July 2021 at a single tertiary care teaching center were retrospectively reviewed. Eight surgeons and 25 anesthesiologists contributed patients, with approach dictated by practitioner preference. Data collected included patient demographics, surgical and anesthetic details, and operating room (OR) utilization metrics. Post-operative complications were evaluated and aggregated, including recurrent hernia, metachronous hernia, hematoma, hydrocele, testicular atrophy, and acquired cryptorchidism. Descriptive statistics were performed with R Studios (p < 0.05).

RESULTS

Of the 338 patients included for analysis, most underwent an open procedure (n = 275) while anesthetic technique was evenly split between GA (n = 185) and caudal (n = 153). Most patients were male (87.6%) and born premature: mean gestational age of 31.4 ± 4.1 weeks. MIS-to-Open conversion was noted once (3.3%) in the GA MIS group, but none in caudal. Median follow up was 2.5 (1.4-3.8) years. No differences were noted in aggregate surgical complication rates (p = 0.4). The Caudal Open group had the shortest total OR time (p < 0.01); caudal anesthesia shortened post-procedure times (p < 0.01).

CONCLUSION

MIS IHR performed under caudal block and sedation yields comparable complication rates compared to the open approach or GA. Open IHR with caudal blockade was the most efficient operative room utilization.

TYPE OF STUDY

Original Article, Clinical Research.

LEVELS OF EVIDENCE

Level III.

Modified Laparoscopic Percutaneous Extraperitoneal Closure Using a Sledge-Shaped Needle for Inguinal Hernia and Hydrocele in 1199 Pediatric Patients

Background: The objective of the study is to determine the safety and efficiency of the modified laparoscopic percutaneous extraperitoneal closure (LPEC) to treat pediatric patients with inguinal hernia or hydrocele. Methods: From January 2014 to July 2018, the patients with inguinal hernia or hydrocele who were operated on using modified LPEC were included. We modified LPEC with a sledge-shaped needle and reinforcement flag. By means of medial umbilical fold, the reinforcement surgery should be performed on the patients with huge internal rings (diameter >1.5 cm). Operative time, complication rate, incidence of reinforcement, and contralateral patent processus vaginalis were described between inguinal hernia and hydrocele. Results: In this study, 764 patients with inguinal hernia and 435 patients with hydrocele were successfully performed by the modified LPEC. The 383 (50.1%) patients with inguinal hernia and 266 (61.1%) patients with hydrocele were identified with a contralateral patency of internal ring and underwent simultaneous prophylactic surgery. During surgical procedures, the medial umbilical fold reinforcement (inguinal hernia/hydrocele = 50/1) was performed on 51 patients. Hernia recurrence occurred in 2 cases. All patients had a good cosmetic appearance without additional dissection. Conclusion: Modified LPEC using a sledge-shaped needle and applying the medial umbilical fold reinforcement is a safe and effective surgical procedure.

Comparison of laparoscopic percutaneous internal ring suturing method and open inguinal hernia repair in children under 3 months of age

Objective: Laparoscopic inguinal hernia repair in younger infants has not been completely accepted worldwide. The aim of this study was to evaluate the safety and feasiblity of laparoscopic percutaneous internal ring suturing method in children aged younger than 3 months and compare the recurrence and complication rates with open repair; which may still be mentioned as the gold standard procedure.

Material and Methods: A total of 387 children underwent inguinal hernia repair in the clinic between 2016 and 2019. One hundred and forty of them were under 3 months old and divided into two groups; children who underwent laparoscopic percutaneous internal ring suturing (Group 1) and open surgery (Group 2). Selection of the surgical method was regardless of weight, sex or any patient characteristics other than surgeon’s choice. Operation durations, complications and recurrences were compared between the two groups.

Results: A total of 140 patients underwent surgery due to inguinal hernia. Group 1 included 85 and Group 2 included 55 children. There were two recurrences in each group (p> 0.05). Operative durations were shorter in Group 1 for both; unilateral and bilateral repairs (< 0.0001). There were no intraoperative complications in any group. There was one major postoperative complication in Group 2: iatrogenic undescended testis, and none was observed in Group 1. In the laparoscopic group, 47% of the children who were diagnosed to have unilateral hernia were revealed to have bilateral inguinal hernias (n= 31).

Conclusion: Laparoscopic percutaneous internal ring suturing method seems favourable in terms of operative time. It also has the advantage of detecting contralateral patent processus vaginalis or asymptomatic contralateral inguinal hernia.

A single institution experience with Laparoscopic Hernia repair in 791 children

INTRODUCTION

There are many described technique to performing laparoscopic inguinal hernia repair in children. We describe our outcomes using a percutaneous internal ring suturing technique.

METHODS

A retrospective review of patients under 18 years old who underwent repair between January 2014 - March 2019 was performed. A percutaneous internal ring suturing technique, involving hydro-dissection of the peritoneum, percutaneous suture passage, and cauterization of the peritoneum in the sac prior to high ligation, was used. p < 0.05 was considered significant during the analysis.

RESULTS

791 patients were included. The median age at operation was 1.9 years (IQR 0.37, 5.82). The median operative time for a unilateral repair was 21 min (IQR 16, 28), while the median time for a bilateral repair was 30.5 min (IQR 23, 41). In total, 3 patients required conversion to an open procedure (0.4%), 4 (0.6%) experienced post-operative bleeding, 9 (1.2%) developed a wound infection, and iatrogenic ascent of testis occurred in 10 (1.3%) patients. Twenty patients (2.5%) developed a recurrent hernia. All but two were re-repaired laparoscopically.

CONCLUSIONS

The use of percutaneous internal ring suturing for laparoscopic repair of inguinal hernias in the pediatric population is safe and effective with a low rate of complications and recurrence.

Long-term outcomes of pediatric laparoscopic needled-assisted inguinal hernia repair: A 10-year experience

PURPOSE

Laparoscopic inguinal hernia repair (LIHR) has gained wide acceptance over the past decade, although studies with longer term follow-up are lacking. We present one of the largest cohorts of children undergoing laparoscopic needle-assisted repair (LNAR) with long-term follow-up.

METHODS

A clinical quality database was maintained for children ≤14 years of age who underwent laparoscopic needle-assisted repair between 2009 and 2017 with review of follow-up through 2019. De-identified data was reviewed.

RESULTS

1023 patients with 1457 LNAR were included during the 10-year period. Mean age at surgery was 2.56 years (2 days to14 years). The overall hernia recurrence rate was 0.75% (11/1457). A total of four postoperative hydroceles required intervention. Preterm infant repair done <60w post conceptional age had a significantly lower recurrence rate (0.63%) than other patients (0.82%) (p < 0.01). 64.2% of patients had clinical follow-up over a period of 11 years with a mean follow-up of 5.97 years.

CONCLUSION

We present a large cohort study of consecutive pediatric laparoscopic hernia repairs followed over an 11-year period. LNAR is safe and effective for term and preterm patients with similar complication rates to other techniques, including open repair. Additionally, our results suggest that preterm infants may have superior outcomes with this method.

LEVEL OF EVIDENCE

Level III - Retrospective Comparative Study.

Laparoscopic versus open herniorrhaphy for children with inguinal hernia: A meta-analysis of randomized controlled trials

PURPOSE

The aim of this study was to compare the effectiveness between laparoscopic herniorrhaphy (LH) and open herniorrhaphy (OH) in children with inguinal hernia.

METHODS

PubMed, EmBase, and the Cochrane library were searched to select trials from their inception till April 2019. The summary of relative risks (RRs) and weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were employed to evaluate the treatment effectiveness between LH and OH.

RESULTS

Six randomized controlled trials (RCTs) including a total of 594 children were selected. No significant differences were observed between LH and OH regarding the risk of postoperative complications. However, LH significantly reduced the risk of major postoperative complications when compared with OH. Moreover, LH showed association with a shorter operative time in bilateral inguinal hernia when compared with OH, whereas no significant difference between groups for unilateral inguinal hernia. Finally, children who received LH showed association with longer time to discharge than those who received OH, whereas no significant difference was observed between the groups for time to resume full activity.

CONCLUSIONS

These findings suggested that children who received LH had protection against major postoperative complications than those who received OH. Moreover, children who received LH had shorter operative time, and longer time to discharge.

Comparative Analysis of Laparoscopic Inguinal Hernia Repair in Neonates and Infants

BACKGROUND

This study analyzed our cohort of infants (age below 12 mo) who underwent laparoscopic inguinal hernia repair (LIHR), comparing those 3 months and below (corrected premature) to above 3 months (term infants) corrected age at the time of surgery.

MATERIALS AND METHODS

Retrospective analysis of a single surgeon and associated trainees' experience of LIHR in infants below 12 months over a 5-year period (2013-2018) was performed. The operative technique involved a 5-mm scope and 3-mm instruments for herniorrhaphy with 4/0 Prolene purse-string suture. Data collected included patient demographics, prematurity (<37 wk), corrected age and weight at surgery, preoperative hemoglobin level, comorbidities, anesthetic time, major perioperative complications, and inguinal hernia recurrence. A comparison was made between those operated at 3 months and below and above 3 months corrected age. Perioperative issues affecting infants 3 months and below were identified and analyzed. Statistical analysis includes T test and Fisher exact test (P<0.05 significance).

RESULTS

Eighty infants underwent LIHR (age below 12 mo), of which 67 (84%) were male with a median corrected age of 10.5 (range 2.5 to 44) weeks, the median weight of 5.5 kg (range 2.1 to 10.8). A total of 47 (59%) infants had a unilateral inguinal hernia repair and 33 (41%) had a bilateral repair. The median anesthetic time was significantly greater for infants 3 months and below at 93 (range 61 to 125) minutes, compared with 83 (range 47 to 146) minutes for the above 3 months age group (P=0.001) There were no perioperative complications or mortality. One patient had a recurrence of an inguinal hernia. Low hemoglobin levels, comorbidities, and extreme prematurity required more attention during preoperative assessment and postoperative management.

CONCLUSIONS

Comparable cohorts demonstrated no significant difference in recurrences despite significant differences in weight and median anesthetic time. Preoperative hemoglobin is an important factor that needs to be addressed in infants 3 months and below for scheduling the procedure date (transfusion vs. iron supplementation).

Inguinal Hernia in Premature Infants

Inguinal hernia is a common problem affecting infants in the NICU. As a group, preterm infants have the highest incidence of inguinal hernia and this risk increases as gestational age decreases. The etiopathologic factors leading to the development of an inguinal hernia are not clear and interventions to alter these factors have not been thoroughly investigated. Diagnosis of an inguinal hernia is often straightforward, but occasionally it may be difficult to determine if the hernia is strangulated or simply obstructed. Rarely, investigative modalities, such as ultrasonography, may be needed to rule out other potential causes. The ideal timing of surgical repair in this population is unknown and complicated by comorbid conditions and limited randomized controlled trials. During surgery, the choice of regional versus general anesthesia requires a team-based approach and studies have found that greater clinical experience is associated with lower morbidity. The techniques of hernia surgery range from open to laparoscopic repair and have been investigated in small prospective studies, while larger databases have been used to analyze outcomes retrospectively.

Our Laparoscopic Surgical Technique and Experience in Treating Pediatric Inguinal Hernia Over the Past Decade

Background:

Over the past decade, laparoscopic hernia repair was the most performed operation in our department. Equally, it compromises 15% of all pediatric operations performed. We aim, in this study, to review all the cases performed and extrapolate important information like reoccurrences, the incidence of metachronous inguinal hernia, complications amongst other information.

Material and Methods:

All patients under the age of 18 whom underwent elective laparoscopic hernia repair between 03/01/2007 till the 18/05/2016 were included in our study. We recorded important clinical features and studied their post-operative follow up. Equally reoccurrences, the incidence of metachronous inguinal hernia, complications and other parameters were recorded and studied.

Results:

A total of 916 patients were operated on during the defined study period. There was a 0.17% reoccurrence rate and a 0.46% incidence of metachronous inguinal hernia. Equally a contralateral patent processus vaginalis was diagnosed and closed in 17.10%. There were no postoperative complications and we had a 0% postoperative hydrocele rate.

Conclusion:

Laparoscopic hernia repair is safe and carries all the benefits of minimally invasive surgery. We recommend that it is offered to patients and would like to refute previously claimed reports that it carries a higher reoccurrence rate or takes a long time to perform. Our reoccurrence rate of 0.17% is actually lower than many published reoccurrence rates after open repair.

Laparoscopic versus open pediatric inguinal hernia repair: state-of-the-art comparison and future perspectives from a meta-analysis

BACKGROUND

Laparoscopic inguinal hernia repair in children is increasingly performed as it allows contralateral inspection and potentially results in shorter operation time and less complications. Evidence from meta-analyses of randomized controlled trials (RCTs) regarding the superiority of laparoscopic versus open hernia repair is lacking.

METHODS

A systematic literature search was performed querying PubMed, Embase, MEDLINE, and the Cochrane Library databases. RCTs comparing laparoscopic with open hernia repair in children were considered eligible, without year and language restrictions. Cochrane Risk of Bias tool was used for quality assessment. Data were pooled using a random-effects model. Subgroup analyses were performed according to the laparoscopic suturing technique (i.e., intracorporeal or extracorporeal).

RESULTS

Eight RCTs (n = 733 patients; age range 4 months-16 years) were included in this meta-analysis. Laparoscopic (LH) and open (OH) hernia repair was performed in 375 and 358 patients, respectively. Complications (seven RCTs, n = 693; pooled OR 0.50, 95% CI 0.14 to 1.79), recurrences (seven RCTs, n = 693; pooled OR 0.88, 95% CI 0.20 to 3.88), and MCIH rates (four RCTs, n = 343; pooled OR 0.28, 95% CI 0.04 to 1.86) were not different between the groups. LH resulted in shorter bilateral operation time (Five RCTs, n = 194; weighted mean difference (WMD) - 7.19, 95% CI - 10.04 to - 4.34). Unilateral operation time, length of hospital stay, and time to recovery were similar. There was insufficient evidence to assess postoperative pain and wound cosmesis, and evidence of substantial heterogeneity between the included studies. Subgroup analyses demonstrated less complications and shorter unilateral operation time for extracorporeal suturing and shorter length of hospital stay for intracorporeal suturing.

CONCLUSIONS AND RELEVANCE

No definite conclusions to decide on the superiority of one of either treatment strategies can yet be drawn from the available literature. There was evidence of substantial heterogeneity and the clinical relevance of most estimated effects is very limited.

Laparoscopic repair of inguinal hernia in infants: Comparison with open hernia repair

PURPOSE

This study aimed to evaluate the usefulness of laparoscopic repair of inguinal hernia (LR) in infants in comparison with open hernia repair (OR).

METHODS

We retrospectively analyzed the clinical data of 465 infants treated for inguinal hernia from January 2006 to December 2015. Among them, 124 underwent LR and 341 underwent OR.

RESULTS

In the OR group, 16.1% (55/341) primarily underwent bilateral inguinal hernia repair and 13.6% (42/308) subsequently developed metachronous contralateral inguinal hernia during follow-up. In the LR group, 75.8% (94/124) underwent primary bilateral inguinal hernia repair and only 1.6% (2/123) developed metachronous contralateral inguinal hernia. The mean operation times of unilateral inguinal hernia repair showed no statistical differences between LR and OR. However, the mean operation times of bilateral inguinal hernia repair were shorter in LR (39.8±10.4 vs. 51.1±14.4min, p<0.001). Postoperative recurrence and wound infection showed no statistical differences between the groups, but postoperative scrotal swelling was more common in OR (0.0% vs. 4.0%, p=0.006).

CONCLUSION

LR in infants showed a lower incidence of metachronous hernia, shorter operation times, and better postoperative course than OR. LR could be considered the primary operation method in infants with inguinal hernia.

LEVELS OF EVIDENCE

Prognosis Study, Retrospective Study, Level III.

Evidence supporting laparoscopic hernia repair in children

PURPOSE OF REVIEW

Pediatric inguinal hernias are a commonly performed surgical procedure. Currently, they can be approached via open or laparoscopic surgery. We summarize the current evidence for laparoscopic inguinal hernia repairs in children.

RECENT FINDINGS

Laparoscopic and open inguinal hernia repair in children are associated with similar operative times for unilateral hernia, as well as similar cosmesis, complication rates and recurrence rates. Bilateral hernia repair has been shown to be faster through a laparoscopic approach. The laparoscopic approach is associated with decreased pain scores and earlier recovery, although only in the initial postoperative period. Laparoscopy allows for easy evaluation of the patency of contralateral processus vaginalis, although the clinical significance of and need for repair of an identified defect is unclear.

SUMMARY

Laparoscopic surgery for pediatric inguinal hernias offers some advantages over open repair with most outcomes being equal. It should be considered a safe alternative to open repair to children and their caregivers.

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

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.

One trocar needlescopic assisted inguinal hernia repair in children: a novel technique

BACKGROUND

Inguinal hernia repair using a percutaneous internal ring suturing technique is an effective alternative technique to conventional laparoscopic hernia repair. It is one of the most commonly used approaches for laparoscopic hernia repair in children. However, most percutaneous techniques have utilized extracorporeal knotting of the suture and burying the knot subcutaneously. This approach has several drawbacks. The aim of this study is to present a modified technique for single cannula needlescopic assisted hernia repair in children.

PATIENTS AND METHODS

Three-hundred and fifty-seven patients with 397 indirect inguinal hernias underwent a one port needlescopic assisted inguinal hernia repair. The open internal inguinal ring [IIR] was closed using an 18-gauge epidural needle [EN], a 14-gauge venous access cannula [VAC], and a homemade suture device. Saline was injected extraperitoneally around the IIR for hydrodissection. The main outcome measurements were: feasibility, safety of the technique, operative time, recurrence rate, and cosmetic results.

RESULTS

This prospective study was conducted on 357 patients at Al-Azhar, Alexandria, and Mansoura University Hospitals during the period from June 2012 to October 2015. There were 286 males and 71 females. The mean age was 2.6±1.3years (range=4months to 6years). One-hundred and ninety-eight patients presented with a right-sided inguinal hernia, 119 patients with a left-sided hernia, and 40 patients with bilateral inguinal hernia. The mean operative time was 12.6±1.7min (range=8-15min) for unilateral cases and 18.6±1.7min (range=14-20min) for the bilateral repairs. No wound complications or umbilical hernias developed. The mean follow-up period was 18.6±1.2months (range=11-36months). During the follow-up period, no recurrence was detected, and the scars were nearly invisible.

CONCLUSION

This preliminary study shows that a single port needlescopic assisted hernia repair in infants and children is a very promising technique to achieve nearly scarless surgery. The procedure is very safe, rapid, easy to learn, and reproducible.

Laparoscopic versus open inguinal hernia repair in children ≤3: a randomized controlled trial

PURPOSE

Laparoscopy is being increasingly applied to pediatric inguinal hernia repair. In younger children, however, open repair remains preferred due to concerns related to anesthesia and technical challenges. We sought to assess outcomes after laparoscopic and open inguinal hernia repair in children less than or equal to 3 years.

METHODS

A prospective, single-blind, parallel group randomized controlled trial was conducted at three clinical sites. Children ≤3 years of age with reducible unilateral or bilateral inguinal hernias were randomized to laparoscopic herniorrhaphy (LH) or open herniorrhaphy (OH). The primary outcome was the number of acetaminophen doses. Secondary outcomes included operative time, complications, and parent/caregiver satisfaction scores.

RESULTS

Forty-one patients were randomized to unilateral OH (n = 10), unilateral LH (n = 17), bilateral OH (n = 5) and bilateral LH (n = 9). Acetaminophen doses, LOS, complications, and parent/caregiver scores did not differ among groups. Laparoscopic unilateral hernia repair demonstrated shorter operative time, a consistent finding for overall laparoscopic repair in univariate (p = 0.003) and multivariate (p = 0.010) analysis. No cases of testicular atrophy were documented at 2 (SD = 2.7) years.

CONCLUSION

Children ≤3 years of age in our cohort safely underwent LH with similar pain scores, complications, and recurrence as OH. Parents and caregivers report high satisfaction with both techniques.

Complications in common general pediatric surgery procedures

Complications related to general pediatric surgery procedures are a major concern for pediatric surgeons and their patients. Although infrequent, when they occur the consequences can lead to significant morbidity and psychosocial stress. The purpose of this article is to discuss the common complications encountered during several common pediatric general surgery procedures including inguinal hernia repair (open and laparoscopic), umbilical hernia repair, laparoscopic pyloromyotomy, and laparoscopic appendectomy.

The laparoscopic approach for repair of indirect inguinal hernias in infants and children

Repair of an indirect inguinal hernia is one of the most common operations performed around the world by pediatric surgeons. Until the last 15 years, most inguinal hernia repairs were performed using an inguinal crease incision and extraperitoneal ligation of the patent processes vaginalis. However, since 2000, the laparoscopic approach has gained popularity and there have been increasing descriptions about various techniques for laparoscopic hernia (LH) repair. At our institution, we have transitioned the majority of inguinal hernia repairs to the laparoscopic approach. In this article, we will describe the technique that is utilized at Children's Mercy Hospital in Kansas City, Missouri (USA) and express our thoughts on the current debate regarding laparoscopic versus open inguinal hernia repair in infants and children.

Current concepts in the management of inguinal hernia and hydrocele in pediatric patients in laparoscopic era

The surgical repair of inguinal hernia and hydrocele is one of the most common operations performed in pediatric surgery practice. This article reviews current concepts in the management of inguinal hernia and hydrocele based on the recent literature and the authors׳ experience. We describe the principles of clinical assessment and anesthetic management of children undergoing repair of inguinal hernia, underlining the differences between an inguinal approach and minimally invasive surgery (MIS). Other points discussed include the current management of particular aspects of these pathologies such as bilateral hernias; contralateral patency of the peritoneal processus vaginalis; hernias in premature infants; direct, femoral, and other rare hernias; and the management of incarcerated or recurrent hernias. In addition, the authors discuss the role of laparoscopy in the surgical treatment of an inguinal hernia and hydrocele, emphasizing that the current use of MIS in pediatric patients has completely changed the management of pediatric inguinal hernias.

The Role of Laparoscopy in the Acute Neonatal Abdomen

Introduction.The surgical treatment of the acute neonatal abdomen still poses a challenge in pediatric surgery. Various underlying etiologies require different surgical procedures. Until today the role of laparoscopy in the surgical treatment of the acute neonatal abdomen is controversial. The aim of this study was to analyze our experiences with laparoscopy and to perform a review of the literature. Methods. Retrospective, single-institution study including all term and preterm neonates initially undergoing laparoscopy due to an acute abdomen. Results. Altogether, 17 neonates presenting with an acute neonatal abdomen initially underwent laparoscopy. Unnecessary laparotomy could be avoided in 9 of 17 (53%) neonates. After diagnostic laparoscopy, 2 patients did not require any further surgical intervention. Eight neonates presented midgut atresia intraoperatively, 5 of them underwent laparoscopic-assisted correction. Successful laparoscopic derotation of an acute volvulus (n = 1) and laparoscopic appendectomy (n = 1) could be performed. Conversion to open surgery was necessary in 8 neonates (47%) due to creation of a stoma (n = 5), multiple intestinal bands causing poor visualization (n = 2), and bowel necrosis (n = 1). Conclusions. Laparoscopy is a useful diagnostic tool to evaluate the need for further surgical intervention in the acute neonatal abdomen and enables immediate surgical treatment of acute volvulus, appendicitis, or intestinal atresia. In case of conversion to laparotomy, precise localization of the incision is guaranteed. Minimization of the surgical trauma and avoidance of unnecessary laparotomy are the most important benefits of the minimal-invasive approach for the critically ill neonate.

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

OBJECTIVE

To summarize experiences and discuss the reasons for postlaparoscopic indirect inguinal hernia recurrence in children.

PATIENTS AND METHODS

From June 2008 to June 2013, 6120 laparoscopic inguinal hernia repairs were performed in our hospital involving 5382 males and 738 females. The average age was 3.1 years. When pneumoperitoneum was established, the laparoscopic lens and a clamp were placed into the upper and lower edges of the umbilicus, respectively. Then on the surface projection of the unclosed internal ring, a sled-like needle with suture was circled and tightened on the internal ring at the extraperitoneum.

RESULTS

Patients were followed up for between 6 months to 5 years. A total of 21 cases developed recurrent hernia (0.3%). Three main surgical causes of recurrence were concluded: (1) the internal inguinal ring was weak and significantly expanded, especially underneath the internal ring, which led to the peritoneum nearby the internal ring sliding through; (2) a sled-like needle repeatedly perforated the peritoneum, or some of the peritoneum left was unsutured, usually causing a hydrocele; and (3) there was an unexpected release of the ligature around the hernial ring. The majority of recurrent hernias could be cured laparoscopically (n=18), but a small number needed an open repair (n=3).

CONCLUSIONS

Recurrent hernia still appeared postlaparoscopic inguinal hernia in a small number of patients. The main preventive measures were removal of risk factors for hernia and an appropriate surgical approach.

Inguinal hernia in neonates and ex-preterm: complications, timing and need for routine contralateral exploration

BACKGROUND/PURPOSE

Aim of this study was to present a series of neonates and ex-preterm babies who underwent inguinal hernia repair focusing on complications and possible indication to perform routine contralateral groin exploration.

METHODS

This is a retrospective study of a series of consecutive patients weighing less than 5 kg who underwent inguinal hernia repair between January 2007 and December 2012. Only the affected side was treated. Patients have been routinely followed up postoperatively. We resorted to available outpatients' charts and admission notes to record demographic data, surgical details, complications and the occurrence of metachronous hernias. A questionnaire was administered to all patients' relatives to confirm the long-term outcome.

RESULTS

One hundred fifty-four patients were operated for a total of 184 herniotomies (88 right sided, 36 left sided and 30 bilateral). Median length of follow-up was 42 months (range 6 months-7.5 years). Thirteen patients (13/124 = 10.5 %) developed metachronous hernia that proved to be significantly more frequent in patients weighing less than 1,500 g at birth (p < 0.05). We observed 10 % of complications, including 2.7 % testicular atrophy and 4.5 % recurrence. Atrophy proved to occur more frequently in patients who experienced preoperative incarceration (p < 0.05). No other risk factors were identified.

CONCLUSIONS

The results of our series demonstrated that, though technically demanding, herniotomy in the neonate and ex-preterm is associated with a relatively low incidence of complications. Based on our results and in accordance with literature data, we do not advocate routine contralateral exploration in case of unilateral hernia but surgery to be performed only on the symptomatic side, as soon as possible after initial diagnosis. Very low birth weight patients should be followed with care in the early postoperative period due to the higher likelihood of developing a metachronous hernia.

Awake caudals and epidurals should be used more frequently in neonates and infants

The current literature provides fundamental insights regarding the neurotoxic potency of various general anesthetic drugs in neonates and small infants. Therefore, considerations to minimize the use of general anesthetic drugs in this age group are required. The use of caudal and epidural anesthesia under sedation is one possibility to minimize the use of general anesthetic drugs. A large number of surgical procedures can be managed with this anesthetic concept. Training, practical hand skills, good infrastructure, a well-defined indication, and a team approach including the entire operation room staff are the major prerequisites to implement these techniques in the daily clinical practice. This review article discusses all present aspects and possible future evolutions of caudal and epidural anesthesia under sedation.

Management of inguinal hernia in premature infants: 10-year experience

AIM

Debatable issues in the management of inguinal hernia in premature infants remain unresolved. This study reviews our experience in the management of inguinal hernia in premature infants.

MATERIALS AND METHODS

Retrospective chart review of premature infants with inguinal hernia from 1999 to 2009. Infants were grouped into 2: Group 1 had repair (HR) just before discharge from the neonatal intensive care unit (NICU) and Group 2 after discharge.

RESULTS

Eighty four premature infants were identified. None of 23 infants in Group 1 developed incarcerated hernia while waiting for repair. Of the 61 infants in Group 2, 47 (77%) underwent day surgery repair and 14 were admitted for repair. At repair mean postconceptional age (PCA) in Group1 was 39.5 ± 3.05 weeks. Mean PCA in Group 2 was 66.5 ± 42.73 weeks for day surgery infants and 47.03 ± 8.87 weeks for admitted infants. None of the 84 infants had an episode of postoperative apnea. Five (5.9%) infants presented subsequently with metachronous contralateral hernia and the same number of infants had hernia recurrence.

CONCLUSIONS

Delaying HR in premature infants until ready for discharge from the NICU allows for repair closer to term without increasing the risk of incarceration. Because of low occurrence of metachronous hernia contralateral inguinal exploration is not justified. Day surgery HR can be performed in former premature infant if PCA is >47 weeks without increasing postoperative complications.

Laparoscopic versus open inguinal hernia repair in pediatric patients: a systematic review

AIM

Inguinal hernia is one of the most common surgical conditions in infants and children. However, considerable debate exists regarding the role of laparoscopic hernia repair (herniorrhaphy) (LH) and its benefits over conventional open hernia repair (herniorrhaphy) (OH). The aim of this review is to analyze the current literature to determine the outcome of LH compared with OH.

MATERIALS AND METHODS

A literature search was performed on all studies published during the last 20 years, reporting on outcomes of OH and LH, in terms of operative time, recurrence rate and other complications, finding of rare hernias, and incidence of contralateral patency. The chi-squared or Fisher's exact test was used to analyze the results of the study.

RESULTS

Fifty-three studies matched our inclusion criteria. As for operative time, in unilateral inguinal hernia repair, there was no significant difference between LH and OH (P=.33). In contrast, in bilateral disease, LH is faster than OH (P=.01). As for the recurrence rate, no significant difference was observed between the two techniques (P=.66), whereas the rate of other complications was significantly higher for OH compared with LH (P=.001). Laparoscopy has the advantage to identify and treat rare hernias (direct, femoral, "en pantalon") that are never reported in articles focused on inguinal OH. In laparoscopic series, in the case of unilateral hernia, the incidence of contralateral patency varied between 19.9% and 66%.

CONCLUSIONS

In this systematic review, it seems that LH is faster than OH for bilateral hernias, whereas there is no significant difference in terms of operative time for unilateral inguinal hernia repair. Recurrence rate is similar for both techniques. As for other complications such as wound infections, it is higher for OH compared with LH, especially in infants. A prospective comparative study is necessary on this topic to strongly support the results of our systematic review.

Neonatal laparoscopic inguinal hernia repair: a 3-year experience

PURPOSE

To retrospectively analyze the feasibility, safety and complication rate of laparoscopic inguinal herniorraphy in babies weighing 5 kg or less.

METHODS

Thirty infants weighing 5 kg or less underwent laparoscopic inguinal hernia repair during a 3-year period. Twenty-eight infants were born preterm and the mean body weight at surgery was 3,800 kg. Internal inguinal ring was closed with a non-absorbable purse-string suture. Contralateral processus vaginalis was closed if patent. Feeding was started on the same day and the patient discharged the following day. Follow-up consisted of physical examination at 1 week, 6 and 12 months post-operatively.

RESULTS

Of the 30 patients (27 males, 3 females), 11 had bilateral and 19 monolateral hernia (16 right, 3 left). At laparoscopy, 23 infants needed to have bilateral herniorraphies. The mean corrected gestational age at surgery was 49.1 weeks. The mean operative time for repair was 30 min for unilateral and 41 min for bilateral hernia. There were not intra- or post-operative complications as well as conversions or recurrences.

CONCLUSIONS

Laparoscopic inguinal hernia repair in newborns and in ex-preterm infants is a safe and effective procedure to perform and, perhaps, even less technically demanding than open herniotomy.

Cardiorespiratory complications after laparoscopic hernia repair in term and preterm babies

PURPOSE

The aim of this study was to clarify the incidence of postoperative complications in infants undergoing laparoscopic hernia repair within the first six months of life.

METHODS

Retrospective, single-institution study comparing term and preterm babies undergoing surgery between March 2005 and September 2012. The charts were reviewed for postoperative complications and pre-existing diseases.

RESULTS

In the term group 188 of 199 babies (94.5%) had an uneventful postoperative course. Eleven patients (5.5%) presented postoperative complications, three of them (1.5%) developed severe respiratory complications. A relation between pre-existing diseases and postoperative complications could be identified in two patients. Laparoscopy possibly induced cardiorespiratory instability in one infant. In the preterm group 109 of 137 babies (79.6%) had an uneventful postoperative course. 28 preterm infants (20.4%) developed postoperative complications, seven of them (5.1%) presented severe respiratory complications. Pre-existing diseases were identified as an influencing factor in 22 preterm infants. In one patient laparoscopy possibly caused minor instability of a pre-existing cardiac anomaly.

CONCLUSIONS

Postoperative complications are low in both groups, although the incidence is increased in preterm infants. Pre-existing diseases are a major influencing factor for preterm infants. In very few infants laparoscopy may have induced instability of cardiac anomalies.