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

Minimally invasive surgery in the operating rooms near you

PURPOSE OF REVIEW

This review delineates the benefits of minimally invasive surgery (MIS) and its utilization at surgical centers and our institution. It further explores the literature for comparative outcomes of performing MIS to traditional open surgery for a variety of surgical subspecialties.

RECENT FINDINGS

In addition to its proven safety when compared to the open surgical technique, MIS has broad applications in many surgical subspecialties to enhance perioperative outcomes in both pediatric and adult patients.

SUMMARY

Although there are certain disadvantages with regard to cost of implementation in nascent communities and total operating time when the surgical complexity increases (such as utilizing a robotic approach), the added benefit of improved patient outcomes due to smaller incision sites is repeatedly proven in the literature making this technique globally essential.

Surgical methods and outcomes of inguinal hernia repair in children, adolescents and young adults in a retrospective cohort study

Laparoscopic repair as an alternative option for pediatric inguinal hernia has increased worldwide. We aimed to analyze the surgical methods of inguinal hernia repair among children, adolescents and young adults, and evaluate the surgical outcomes of reoperation and postoperative complications. This is a hospital-based retrospective cohort study. 3249 inpatients who were ≤ 25 years and underwent inguinal hernia repair between 2015 and 2021 were included. Baseline data, hernia characteristics, surgical approach and technique, outcomes including reoperation and postoperative complications before discharge were identified from electronic medical records. Multivariable Cox regression and logistic regression were used to analyze the association between surgical methods and outcomes. Of all participants, 72.82% were children younger than 9 years, 79.62% were male, 81.19% underwent laparoscopic surgery. Laparoscopic sac high ligation was the mostly used method among infants and children who were younger than 13 years (from 61.11% in 10-12 years old to 96.77% in 0-3 years old), open and laparoscopic tension-free repairs were more common for adolescents and young adults older than 13 years (from 92.38% in 13-15 years old to 100% in 19-21 years old). During a median follow-up of 51.91 months, 24 (0.74%) reoperations were identified, including 3 (0.09%) ipsilateral recurrence, and 21 (0.65%) metachronous contralateral inguinal hernia (MCIH) repair. The rate of complications before discharge was 0.37%. There were no significantly differences in reoperation (aHR = 0.51, 95%CI: 0.12-2.19) and complications (aOR = 0.83, 95%CI: 0.17-4.11) between laparoscopic and open surgery. Age < 3 years (aHR = 6.40, 95%CI: 1.66-24.61), unilateral hernia (aHR = 11.09, 95%CI: 1.46-84.30), and anemia (aHR = 8.58, 95%CI: 1.94-38.05) were independent risk factors for reoperation. Obstruction/gangrene was independent risk factor for complications (aOR = 17.16, 95%CI: 4.07-72.38). Laparoscopic sac high ligation was most commonly performed in children < 13 years, and open and laparoscopic tension-free repairs were more frequently in those > 13 years. Both laparoscopic and open approaches were safe and effective, with low incidence of reoperations and complications.

A Retrospective Nationwide Comparison of Laparoscopic vs Open Inguinal Hernia Repair in Children

BACKGROUND

Utilization of the laparoscopic approach for inguinal hernia repair has increased significantly over the past decade. The purpose of this study is to compare rates of second hernia operation and same side recurrence following open and laparoscopic inguinal hernia repair in a large national cohort.

METHODS

This retrospective analysis utilized the Pediatric Health Information System database to identify children <18 years-old who underwent laparoscopic or open primary inguinal hernia repair from 2017 to 2021. Data were collected through 2022 to allow minimum one year follow-up. Second hernia operation rates, inclusive of same side recurrence and metachronous contralateral hernia, and same side recurrence rates were compared by multivariable mixed effects model controlling for confounders and institutional clustering. Misclassification rates were determined through data validation at four constituent institutions. Sensitivity analyses determined true outcome rates.

RESULTS

We identified 53,287 operations (15.6% laparoscopic). Rate of second hernia operation was greater following laparoscopic repair (2.9% vs 2.6%, p = 0.04) with no difference on multivariable analysis (OR 1.14, 95% CI 0.98-1.32). Same side recurrence rate was greater following laparoscopic repair (1.5% vs 0.4%, p < 0.001) which persisted on multivariable analysis (OR 3.72, 95% CI 2.90-4.78). Sensitivity analysis demonstrated true laparoscopic and open repair rates of 14.2% and 85.8%, respectively. True rates of second hernia operation and same side recurrence were identical to those determined by PHIS.

CONCLUSION

Laparoscopic inguinal hernia repair in children has more than three times the odds of same side hernia recurrence than open repair which is balanced by a reduced rate of second operation for metachronous hernia.

LEVEL OF EVIDENCE

Treatment Study - Level III.

Preferences for Inguinal Hernia Repair in Infants: A Survey of the Eastern Pediatric Surgery Network

INTRODUCTION

Laparoscopic inguinal hernia repair (IHR) is being performed more frequently in children, but few studies have evaluated surgical practice patterns in infants. In this study, we surveyed pediatric surgeons within a regional consortium to assess current preferences for IHR strategy in infants. We hypothesized that early-career pediatric surgeons would prefer laparoscopic IHR over open IHR in this patient population.

METHODS

A Qualtrics survey addressing surgeon preferences for IHR was distributed to 160 pediatric surgeons at 19 member institutions affiliated with the Eastern Pediatric Surgery Network. Surgeons were stratified by self-reported number of years in attending practice. Responses were compared using t-tests and chi-square tests wherever appropriate.

RESULTS

Ninety-eight surgeons responded to the survey (61% response rate; two incomplete responses were excluded). Forty respondents (41.7%) had 0-10 ys of experience, 26 (27.1%) had 10-20 ys of experience, and 30 (31.2%) had over 20 ys of experience. Over 90% of early-career surgeons reported a preference for laparoscopic IHR in infants, compared to less than 50% of mid-career surgeons and less than 20% of late-career surgeons (P < 0.001). Respondents preferring laparoscopic IHR most commonly cited inherent assessment of the contralateral side, confirmation of hernia before repair, and technical ease of the laparoscopic approach as factors contributing to their preference.

CONCLUSIONS

The majority of early-career pediatric surgeons prefer laparoscopic IHR over open IHR in infants, representing a substantial shift away from what is traditionally regarded as the gold standard open technique. Larger studies are needed to compare long-term outcomes after laparoscopic and open IHR in infants.

Is the double-ligation method safe and effective in laparoscopic paediatric inguinal hernia repair? A retrospective cohort study

INTRODUCTION

Laparoscopic paediatric hernia repair has since been performed more frequently. Recently, a double-ligation method was introduced to prevent recurrence in laparoscopic surgery. The objective of our study was to compare the postoperative outcomes of patients who underwent double and single ligations.

PATIENTS AND METHODS

We performed a retrospective review of patients with inguinal hernia who underwent laparoscopic paediatric inguinal hernia repair from 2014 to 2018 at our institution. Patients were divided into two groups and underwent single ligation and double ligation.

RESULTS

Three hundred and six patients (single-ligation group: 142 and double-ligation group: 164) were included. Four patients experienced recurrence, and the recurrence rate was 1.29%. The recurrence rate was significantly higher in the single-ligation group. There were no statistically significant differences in the postoperative complications between the two groups.

CONCLUSION

Double-ligation method in laparoscopic paediatric hernia repair was relatively safe and helpful.

Inguinal hernioplasty in children-open or laparoscopic?: A retrospective cohort study of 1,072 cases

PURPOSE

The most common surgical intervention in childhood is inguinal hernioplasty. The advantage of laparoscopic approach is still questionable, therefore our aim was to compare open hernia repair (OHR) and PIRS (Percutaneous Internal Ring Suturing) technique at the authors' institute.

METHODS

An observational retrospective cohort study was conducted between 2013 and 2021. Patients were included with hernioplasties under 18 years. The number of contralateral patent processus vaginalis, length of hospital stay, complications and recurrences were analysed.

RESULTS

1,072 surgeries were performed (OHR: 836, PIRS: 236) in 959 patients with the mean age of 4.2 years. During the study period 86 incarcerated hernias were treated: 85/86 following successful reduction with postponed surgery (77 open and eight PIRS) and 1/86 acute (open) surgery. Only six complications (OHR: 5, PIRS: 1, p = 0.86) and 22 recurrences were registered (open:15, PIRS: 7, p = 0.22). The average length of hospital stay was 1.13 days (OHR: 1.3, PIRS: 1.13 days, p = 0.82). PIRS identified contralateral patent processus vaginalis in 22.45% of cases initially diagnosed as unilateral.

CONCLUSIONS

Our findings indicate that both techniques are equally safe, with no statistically significant differences observed in terms of hospital stay duration, recurrence rates, or complication rates.

A Data-Driven Approach to Inguinal Hernia Repairs in Infants and Children

Introduction: Laparoscopic inguinal hernia repair has become increasingly popular in children. The laparoscopic technique inherently assesses the contralateral processus vaginalis, reducing the risk of metachronous contralateral hernias. We hypothesized that primary laparoscopic repair would be associated with lower rates of subsequent hernia repair in the youngest patients, in whom metachronous contralateral hernias are most common. Materials and Methods: The Pediatric Health Information System database was queried for patients 0-15 years old, who underwent inguinal hernia repair between 2016 and 2022. The primary outcome was the need for subsequent hernia repair. Current Procedural Terminology (CPT) and ICD-10 procedure codes were used to determine laparoscopic versus open repair. Patients were excluded if the only recorded code was for recurrent hernia or if both laparoscopic and open codes were present for the same procedure. Results: A total of 109,456 patients were included in the study, with 20,338 patients (18.58%), undergoing laparoscopic inguinal hernia repair initially, and 2535 patients (2.32%) requiring a second hernia repair. Patients 6 months old and younger undergoing unilateral laparoscopic repair were less likely to require subsequent surgery (OR 0.82, 95% CI = 0.69-0.96). Across all ages, open bilateral repair less often required subsequent repairs (OR 1.93, 95% CI: 1.48-2.51). Conclusion: Laparoscopic unilateral inguinal hernia repair decreases the need for subsequent surgical repair in infants 6 months and younger. No difference was detected in older patients. Open repair of bilateral hernias decreases the need for a second hernia operation in all age groups, suggesting that open repair is more durable.

Laparoscopic Hernia Sac Transection With Intracorporeal Ligation: A Comparison With Open Hernia Repair in the Pediatric Age Group

Background and objective Inguinal hernia in children results from a failure of the processus vaginalis (PV) to close, leading to herniation. Surgical repair is necessary to prevent complications in this patient population. This study aimed to compare the outcomes between laparoscopic herniotomy (LH) and open herniotomy (OH) in pediatric patients with inguinal hernia. Methods This prospective study included 80 children diagnosed with inguinal hernia between January 2023 and June 2024. Patients aged 1-12 years were classified into two groups: 38 underwent LH, and 42 received OH. Postoperative outcomes, including operative time, pain, hospital stay, and complications, were evaluated. Statistical analysis was performed using descriptive statistics, with a p-value <0.05 considered significant. The t-test, chi-square test, and arithmetic mean with standard deviation (SD) were used for data analysis. Results The mean operative time was significantly longer for LH (97.89 ±18.2 minutes) compared to OH (31.14 ±8.3 minutes) (p<0.001). However, pain assessment revealed no significant difference between the groups (p=0.776). Hospital stay was longer for LH patients, who were discharged on day two, compared to day one for OH patients (p=0.001). No significant differences were observed in surgical site infection (SSI) rates (p=0.090) or return to school (p=0.857). Conclusions Laparoscopic and open hernia repair are comparable in terms of postoperative pain, SSI rates, and return to normal activities. However, OH offers advantages in terms of reduced operative time and shorter hospital stays. Further studies, including randomized controlled trials, are needed to exclude selection bias and provide deeper insights into the topic.

Trans-Abdominal Pre-Peritoneal (TAPP) Approach for Anatomical Repair of Direct Inguinal Hernia in Children: Could it Be the New Standardized Approach?

BACKGROUND

The incidence of direct inguinal hernia in the pediatric population is relatively low and is usually discovered intraoperatively, rendering it unfamiliar to most pediatric surgeons. The traditional approach involves directly addressing the peritoneal defect, which includes dissecting the sac and repairing the peritoneum, reinforced with the umbilical ligament. In this paper, we present our experience with a novel approach to anatomical repair utilizing a non-mesh transabdominal preperitoneal (TAPP) approach.

METHODS

This a retrospective case series of direct inguinal hernia that were operated laparoscopically using the novel approach of repair from January 2018 to January 2024. Data were analyzed for demographics, presentation, type of defect, operative time, complications, and recurrence. The new approach utilizes the pre-peritoneal approach to delineate the exact facial defect then, primary anatomical repair is established using 2/0 non-absorbable braided sutures. Finally, closure of the peritoneum was performed using running 4/0 absorbable sutures. This is a retrospective case series of direct inguinal hernias that were operated on laparoscopically using the novel repair approach from January 2018 to January 2024. Data were analyzed for demographics, presentation, type of defect, operative time, complications, and recurrence. The new approach employs the pre-peritoneal approach to accurately delineate the fascial defect, followed by primary anatomical repair using 2/0 non-absorbable braided sutures. Finally, the peritoneum is closed using running 4/0 absorbable sutures.

RESULTS

Data from nine cases were included. Six cases were on right side, and three cases were on left side. Patients were predominantly boys (8 boys and 1 girl). The mean age at operation was 25.1 months (range:11 month to 5 years). Four patients had previous indirect inguinal hernia repair on the same side. The mean operative time was 34 ± 9 min. No intraoperative complications occurred. The median follow up period was 24 months with no recurrence was detected in any of the cases.

CONCLUSION

The non-mesh TAPP approach offers excellent exposure of the fascial structures, facilitating accurate identification and repair of the defect. Despite being technically demanding, it allows for the establishment of a robust anatomical repair. No recurrences occurred in the study group; however, a longer follow up and a larger sample are needed to provide more reliable evaluation.

LEVEL OF EVIDENCE

III.

Laparoscopy Versus Open Technique for Inguinal Hernia Repair in Children: A Systematic Review and Meta-Analysis

This study aims to compare operative time, recurrence, and complications between laparoscopic and open techniques for the repair of inguinal hernia in children. Pubmed and Embase databases were systematically searched for studies of pediatric patients who underwent open or laparoscopic inguinal hernia procedures. The main outcomes were operative time, recurrence, and complications. Statistical analysis was performed using RevMan 5.4.1 software (The Cochrane Collaboration, Copenhagen), and heterogeneity was assessed using the I² strategy. Four randomized clinical trials were included in the statistical analysis, totaling 662 patients, with 337 patients in the laparoscopic technique group. Operative time was significantly shorter in the laparoscopic technique group (STD -0.75, 95% CI (-1.43, -0.07), P < 0.00001, I² = 92%). Recurrence (RR 0.60, 95% CI (0.18, 2.02), P = 0.54, I² = 0%) and complications (RR 0.49, 95% CI (0.12, 2.03), P = 0.32, I² = 67%) were statistically similar between the two groups. The laparoscopic technique for inguinal hernia repair in children proved to be faster, with similar recurrence and complication rates compared to the open technique.

Inguinal hernias in children: Update on management guidelines

Inguinal hernia repair is one of the most performed procedures in children, but aspects of care remain controversial. The aim of this review was to provide a critical appraisal of recently published guidelines on the management of inguinal hernias in children, by the American Academy of Pediatrics (2023) and the European Pediatric Surgeons' Association Evidence and Guideline Committee (2022). This was achieved by delineating areas of controversy and reviewing the most relevant recent literature on these topics. Currently available moderate-to-low quality evidence recommends postponing hernia repair in premature infants until after discharge, to reduce the risk of respiratory difficulties and recurrence. Laparoscopic repair provides similar outcomes to open but may shorten operative time in bilateral cases. No clear recommendation can be made for contralateral exploration, therefore should be evaluated case by case. In preterm infants, consideration of regional anaesthesia may reduce post-operative apnoea and pain, with no difference in neurodevelopment outcomes.

Comparing Robot-Assisted and Laparoscopic Inguinal Hernia Repair: A Systematic Review and Meta-Analysis

Inguinal hernia repair is a common surgical intervention. Advancements in minimally invasive techniques, specifically laparoscopic (LR) and robot-assisted (RR) approaches, have reshaped the landscape of surgical options. This meta-analysis aimed to systematically assess and compare the effectiveness and safety of laparoscopic and robot-assisted inguinal hernia repair through a comprehensive review of the literature. A systematic search of databases was conducted to identify relevant studies published up to November 30, 2023. Fifteen studies, encompassing a total of 64,568 participants, met the inclusion criteria. Pooled estimates for key outcomes, including duration of operation, overall complications, and surgical site infection (SSI), were calculated using random-effects models. This meta-analysis revealed a statistically significant difference in the duration of surgery, favoring laparoscopic repair over robot-assisted techniques (mean difference: 26.85 minutes, 95% CI (1.16, 52.54)). Overall complications did not significantly differ between the two approaches (odds ratio: 1.54, 95% CI (0.83, 2.85)). However, a significantly greater risk of SSI was identified for robot-assisted procedures (odds ratio: 3.32, 95% CI (2.63, 4.19)). This meta-analysis provides insights into the comparative effectiveness of laparoscopic and robot-assisted inguinal hernia repair. While laparoscopy has shorter operative times and comparable overall complication rates, the increased risk of SSI during robot-assisted procedures necessitates careful consideration in clinical decision-making. Surgeons and healthcare providers should weigh these findings according to patient characteristics, emphasizing a personalized approach to surgical decision-making. The evolving landscape of inguinal hernia repair warrants ongoing research to refine techniques and optimize outcomes for the benefit of patients undergoing these procedures.

Comparative Analysis of Laparoscopic Versus Open Procedures in Specific General Surgical Interventions

Laparoscopic and open surgeries are two distinct surgical approaches with significantly different procedures and outcomes. Minimally invasive surgery, also known as laparoscopic surgery, utilizes small incisions and specialized instruments like the laparoscope to perform procedures. This contrasts with open surgery, which requires larger incisions to directly access the surgical site. Open surgery was the preferred approach for any invasive procedure until the introduction of new technological advances in the form of laparoscopy. While laparoscopy is still evolving, preliminary results demonstrate promise for various operations. Open surgery provides the healthcare professional with more liberty in the form of increased visualization, but it also increases tissue damage and hospital stays. Laparoscopic and open procedures are both valuable surgical methods with advantages and disadvantages. While open surgery is favored for difficult patients, laparoscopic surgery offers a quicker recovery and fewer scars. The choice between the two approaches depends on the patient's condition, surgical demands, and the surgeon's skills. As these methods develop, they become increasingly important for offering safe and efficient surgical treatments across a range of medical specialties.

Development of an international core outcome set for treatment trials in paediatric inguinal hernia: protocol for a three-phase study including a systematic review and Delphi survey

INTRODUCTION

In children, open inguinal hernia repair has been the gold standard for treatment, but with recent technical advancements in laparoscopy, laparoscopic hernia repair is gaining popularity. Despite available results from comparative studies, there is still no consensus regarding the superiority of open versus laparoscopic treatment strategy. An important reason for lack of consensus is the large heterogeneity in the trials' reported outcomes and outcome definitions, which limits comparisons between studies and precludes conclusions regarding the superiority of treatment strategies. The development and implementation of a core outcome set (COS) is a solution for this heterogeneity in the selection, measurement and reporting of trial outcome measures across studies. Currently, there is no COS for the treatment of paediatric inguinal hernia.

METHODS AND ANALYSIS

The aim of this project is to reach international consensus on a minimal set of outcomes that should be measured and reported in all future clinical trials investigating inguinal hernia repair in children. The development process comprises three phases. First, we identify outcome domains associated with paediatric inguinal hernia repair from a patient perspective and through a systematic review of the literature using EMBASE, MEDLINE and the Cochrane Library databases. Second, we conduct a three-step Delphi study to identify and prioritise 'core' outcomes for the eventual minimal set. In the third phase, an expert meeting is held to establish the final COS and develop implementation strategies with participants from all stakeholder groups: healthcare professionals, parents and patients' representatives. The final COS will be reported in accordance with the COS-Standards for Reporting statement.

ETHICS AND DISSEMINATION

The medical research ethics committee of the Amsterdam UMC confirmed that the Dutch Medical Research Involving Human Subjects Act (WMO) does not apply to this study and that full approval by the committee is not required. Electronic informed consent will be obtained from all participants. Results will be presented in peer-reviewed academic journals and at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42021281422.

Perioperative management of infant inguinal hernia surgery; a review of the recent literature

Inguinal hernia surgery is one of the most common electively performed surgeries in infants. The common nature of inguinal hernia combined with the high-risk population involving a predominance of preterm infants makes this a particular area of interest for those concerned with their perioperative care. Despite a large volume of literature in the area of infant inguinal hernia surgery, there remains much debate amongst anesthetists, surgeons and neonatologists regarding the optimal perioperative management of these patients. The questions asked by clinicians include; when should the surgery occur, how should the surgery be performed (open or laparoscopic), how should the anesthesia be conducted, including regional versus general anesthesia and airway devices used, and what impact does anesthesia choice have on the developing brain? There is a paucity of evidence in the literature on the concerns, priorities or goals of the parents or caregivers but clearly their opinions do and should matter. In this article we review the current clinical surgical and anesthesia practice and evidence for infants undergoing inguinal hernia surgery to help clinicians answer these questions.

Laparoscopic versus Open Incarcerated Inguinal Hernia Repair in Children: A Systematic Review and Meta-Analysis

BACKGROUND

 Laparoscopic hernia repair (LH) is reported to have superior outcomes in pediatric inguinal hernia repair, but its advantages in incarcerated inguinal hernia (IIH) are not defined. We compare the outcomes of LH versus open hernia repair (OH) for pediatric IIH.

METHODS

 We performed a systematic review on all published analyses of LH versus OH for IIH. We identified studies published in 2000 to 2018 from Medline, PubMed, Embase, Google Scholar, and Cochrane databases. We included only studies that compared both surgical techniques on children aged 18 years or younger. Search terms were variations of "incarcerated inguinal hernia," "hernia repair," "laparoscopy," and "child." We categorized complications as major (testicular atrophy, ascending testis, recurrence, iatrogenic visceral injury) and minor (wound infection). Heterogeneity was assessed using I2; meta-analyses were performed using random- or fixed-effects models as appropriate. Weighted mean differences (WMDs) or odds ratios (ORs), with their corresponding 95% confidence intervals (CIs), were used for analysis of continuous and dichotomous variables, respectively. Significance level was at p-value less than 0.05.

RESULTS

 Our initial search yielded 549 unique citations. Eight retrospective cohort (RC) studies (584 patients) were included in the final analysis (339 LH, 245 OH). Overall, major complications (eight RC; n = 584; OR = 0.38; 95% CI: 0.17-0.88; p = 0.02) were more common in OH. When each complication was assessed individually, there were no differences between groups. The length of hospital stay in the LH group was shorter than in the OH group (five RC; n = 418; WMD = - 1.39; 95% CI, -2.56 to -0.22; p = 0.02).

CONCLUSION

 Laparoscopic repair for IIH is associated with less major complications and shorter hospital stay, but data are limited due to the absence of randomized controlled trials.

Anesthetic management of inguinal hernia in an ex-premature infant with subglottic stenosis: a case report

BACKGROUND

We report the anesthetic management of inguinal hernia repair for an infant with subglottic stenosis. A previously scheduled operation had been cancelled due to unexpected airway trouble during the induction.

CASE PRESENTATION

A boy was born at 24 weeks of gestation and his trachea was intubated for 45 days. At 16 months old, surgery for inguinal hernia was planned, but cancelled due to unexpected narrow airway, and subglottic stenosis was first suspected. At 17 months old, he was transferred to us for inguinal hernia surgery. After careful discussion between the surgical team and the anesthesiologists, a strategy to manage this patient was developed. He underwent open hernia surgery under spinal anesthesia and diagnostic rigid bronchoscopy under tubeless general anesthesia separately, which revealed low-grade stenosis and some subglottic cysts. The postoperative course was uneventful.

CONCLUSION

Interdepartmental discussion weighing risks and benefits may deduce the safest and most appropriate anesthesia method.

Laparoscopic Extraperitoneal Hernia Repair Versus Open Repair in Boys with Inguinal Hernia: A Meta-analysis

OBJECTIVE

Pediatric inguinal hernia is a common surgical problem in boys. Open hernia repair surgery (OH) has been traditionally used to treat this condition, but it leads to complications, such as testicular complications. Laparoscopic hernia repair by using the extraperitoneal method (LHE) is performed through the percutaneous insertion of sutures and extracorporeal closure of patent vaginalis processus; thus, injury to spermatic cord structures is avoided. However, a meta-analysis comparing LHE and OH is lacking.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched for relevant studies. A meta-analysis of the retrieved studies was performed, and a random-effects model was used to calculate the pooled effect size. The primary outcome was testicular complications, including ascending testis, hydrocele, and testicular atrophy. The secondary outcomes were surgical metachronous contralateral inguinal hernia (MCIH), ipsilateral hernia recurrence, and operation time.

RESULTS

In total, 6 randomized controlled trials (RCTs) and 20 non-RCTs involving 17,555 boys were included. The incidence of ascending testis (risk ratio [RR]: 0.38, 95% confidence interval [CI]: 0.18-0.78; p = 0.008) and MCIH (RR: 0.17, 95% CI: 0.07-0.43; p = 0.0002) was significantly lower in LHE than in OH. The incidence of hydrocele, testicular atrophy, and ipsilateral hernia recurrence did not differ between LHE and OH.

CONCLUSION

Compared with OH, LHE led to fewer or equivalent testicular complications without increasing ipsilateral hernia recurrence. Moreover, MCIH incidence was lower in LHE than in OH. Hence, LHE could be a feasible choice with less invasiveness for inguinal hernia repair in boys.

LEVEL OF EVIDENCE

Treatment study, LEVEL III.

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.

Outcome and learning curve for laparoscopic intra-corporeal inguinal hernia repair in children

BACKGROUND

Laparoscopic inguinal hernia repair is one of the procedures most commonly performed by paediatric surgeons. Current research on the learning curve for laparoscopic hernia repair in children is scarce. This study aims to evaluate the clinical outcome and learning curve of laparoscopic intra-corporeal inguinal hernia repair in children.

METHODS

A retrospective single-centre analysis of all paediatric patients who underwent laparoscopic intra-corporeal inguinal hernia repair between 2010 and 2019 was performed. The clinical outcomes were analysed. The data on the achievement of the learning curve by surgical trainees were evaluated with the CUSUM technique, focusing on operative time.

RESULTS

There were 719 patients with laparoscopic intra-corporeal inguinal hernia repair (comprising 1051 sides) performed during the study period. The overall ipsilateral recurrence rate was 1.8% without other complications detected. CUSUM analysis showed that there were 3 phases of training, for which the trainees underwent initial learning phase (Phase 1) for the first 7 cases. After mastering of the skills and extrapolating the skills to male patients with smaller body size (Phase 2), they then achieved performance comparable to that of the senior surgeons after 18 procedures (Phase 3).

CONCLUSIONS

18 procedures seem to be the number required to reach the learning curve plateau in terms of operative time by surgical trainees. The clinical outcomes show that laparoscopic intra-corporeal inguinal hernia repair is a safe and transferrable technique, even in the hands of trainees, with adequate supervision and careful case selection. It also provides skill acquisition for minimally invasive surgery.

Laparoscopic paediatric inguinal hernia repair: lessons learned from 102 cases

INTRODUCTION

Paediatric inguinal hernias (IHs) are common. The first paediatric laparoscopic hernia repair was described by El-Gohary and colleagues in the United Arab Emirates in 1993. Both laparoscopic inguinal hernia repair (LIHR) and open repair still exist concurrently with no consensus on gold standard treatment at present. The purpose of this study was to retrospectively evaluate our initial experience with LIHR in paediatric patients.

METHODS

A retrospective observational cohort study of all paediatric patients that underwent LIHR in our institution was performed. Intraoperative and postoperative outcomes were examined.

RESULTS

During the study period, 102 patients were scheduled for LIHR. The majority (76.5%) were male with a median age of 5 months. Thirty two patients (31.4%) were neonates at the time of surgery. The majority of cases (83.3%) were elective procedures. There were no instances of intraoperative vascular or visceral injury. Most patients underwent surgery as a day case. Eighteen patients underwent bilateral LIHR. The recurrence rate was 1.9%. These occurred in the first two patients to undergo LIHR, after which no recurrences were observed following a modification of the technique. The overall complication rate was 7.1%, most of which were managed conservatively.

CONCLUSION

Paediatric LIHR is a safe, feasible and effective procedure that is associated with a short inpatient length of stay, a low recurrence rate and low postoperative complication rate. The technique is versatile and can be used to treat both elective and emergency presentations with IH in a wide age range.

Review and Quality Assessment of Systematic Reviews and Meta-analyses on the Management of Pediatric Inguinal Hernias: A Descriptive Study

INTRODUCTION

Research quality in pediatric surgery has been challenged by multiple factors, including the low incidence of some congenital pathologies and rare event rates. With the rapid increase of pediatric surgical literature, there is a need for systematic reviews to synthesize evidence. It is important to assess the quality of these systematic reviews.

OBJECTIVE

This study aims to examine the reporting of systematic reviews and meta-analyses, using inguinal hernia repair as an index diagnosis.

METHODS

MEDLINE, Embase, and CINAHL databases were searched for systematic reviews and/or meta-analyses of interventions on inguinal hernia in the pediatric population. The quality reporting was assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) 2 tools.

RESULTS

Of 1449 unique reports, 21 studies were included (15 meta-analyses and six systematic reviews). Median percent reported items for PRISMA and AMSTAR 2 were 72.2% and 70.5%, respectively. The least reported items in PRISMA were protocol registration (27.6%), synthesis of results (13.0%), and a risk of bias across studies (20.6%). For AMSTAR 2, the least reported items were reporting of source of funding (14.3%), appropriate methods for statistical combination of results (25.0%), and pre-establishment of protocol (28.6%). All critical items were completely or partially fulfilled in 5/21 (23.8%) of the studies and completely absent in 1/21 (4.8%) studies.

CONCLUSIONS

The results of this study highlight relatively good reporting quality, yet a poor methodological quality of systematic reviews/meta-analyses in the pediatric surgery literature on inguinal hernia management.

Comparison of Two Laparoscopic Techniques in Management of Pediatric Inguinal Hernias

Introduction: Many studies focus on comparing outcomes of the open method for inguinal hernia repair (IHR) and the laparoscopic method. However, few studies compare different laparoscopic techniques. With over a dozen different techniques described in the literature for laparoscopic IHR, significant opportunities exist to study the efficacy of each technique. We investigated outcomes of a subcutaneous endoscopically assisted transfixion ligation (SEATL) technique and a percutaneous internal ring suturing (PIRS). Materials and Methods: After receiving institutional review board approval, we completed a retrospective chart review of IHR performed at our pediatric tertiary care center between September 2015 and May 2020. We included all patients under the age of 18 years. We separated laparoscopic repairs from total repairs. Laparoscopic repairs were further divided into their respective techniques. Factors involving patient demographics, operative details, and postoperative complications were statistically analyzed using SPSS. Results: There was a total of 131 IHRs performed with SEATL and 124 IHRs performed with PIRS. Median operative time (minutes) differed significantly (P = .001) with SEATL at 49 (28-66) and PIRS at 55 (37-76)] minutes. Significantly more incarcerated hernias were repaired with PIRS (n = 13) than with SEATL (n = 3, P = .006). SEATL had a higher number of postoperative complications; the most significant were granulomas (n = 3, P = .09) and recurrent hernias (n = 12, P < .001). Conclusion: SEATL had a significantly higher number of postoperative complications. This may be a result of multiple factors including but not limited to the absence of electrocautery, a shorter median operative time, and utilization of absorbable suture. Modifications have been made to this technique to reduce risk of postoperative complications.

Single-port laparoscopic percutaneous extraperitoneal internal ring closure for paediatric inguinal hernia using a needle grasper

BACKGROUND

Single-site laparoscopic percutaneous extraperitoneal closure has been widely used for the repair of paediatric inguinal hernia. In this study, we aimed to introduce the usage of a needle grasper in single-port laparoscopic herniorrhaphy in children.

METHODS

In our study, 447 children with inguinal hernia underwent single-port laparoscopic percutaneous extraperitoneal closure between October 2018 and October 2021 in Shenzhen Children' hospital were retrospectively reviewed.

RESULTS

Among 447 patients, there were 396 males and 51 females with a mean age of 2.24 ± 0.36 years. A contralateral patent processus vaginalis was present in 165 unilateral hernia patients. All patients underwent laparoscopic percutaneous extraperitoneal closure successfully without converting to open operation. The mean operating time in unilateral and bilateral hernia patients were 10.23 ± 2.25 mine and 14.54 ± 2.81 mine respectively. One patient had subcutaneous emphysema, two male patients had inguinal hernia recurrence and none had complications such as hydrocele and testicular atrophy. Additional 0.3 cm port was done in 4 cases. The mean follow-up time was 22.36 ± 4.56 months.

CONCLUSIONS

Single-port laparoscopic percutaneous extraperitoneal closure of paediatric inguinal hernia using a needle grasper is a feasible and safe procedure. It has the advantages of fewer skin surgical incisions, short operating time, low complication and low recurrence rate.

Laparoscopic versus open inguinal hernia repair in infants: an initial experience

BACKGROUND

Inguinal hernia repair is a common operation performed in children. In Australia, open repair (OR) continues to be the preferred method of treatment in infants, despite laparoscopic repair (LR) gaining popularity amongst some international centres. Our aim was to analyse initial outcomes with LR at our paediatric centre.

METHODS

We conducted a retrospective review of all patients <1 year of age who received LR or OR between January 2017 and July 2021 at our institution. Data were retrieved from both electronic and scanned medical records. Data were analysed using an unpaired t-test, Mann-Whitney test, Fisher's exact test or simple linear regression. A P-value <0.05 was considered significant.

RESULTS

A total of 376 patients were identified: LR was performed in 73 patients, and OR in 303 patients. Bilateral repair was more common amongst patients receiving LR: 56.2% versus 21.5%, P = 0.0001, treating either a symptomatic hernia or an intra-operative contralateral inguinal defect (70%). All LR patients received general anaesthetic, compared to 82.8% of patients in the OR group, P = 0.0001. There were no recurrences following LR and 3 with OR (P = 1.0). The metachronous contralateral inguinal hernia rate following OR was 10% (21/206). There was no significant difference in other complications, including wound infection, haematoma, testicular atrophy, and hydrocele formation.

CONCLUSION

In our population OR was performed more often than LR. Operative complication rates were equivalent between OR and LR groups. However, infants that underwent OR were significantly more likely to develop a MCIH.

Comparison of laparoscope-assisted single-needle laparoscopic percutaneous extraperitoneal closure versus open repair for pediatric inguinal hernia

Background

Laparoscopic-assisted repairs for pediatric inguinal hernia have gained gradual acceptance over the past decade. However, consensus about the optimal management is still lacking. The aim of this study is to compare outcomes of a modified laparoscope-assisted single-needle laparoscopic percutaneous extraperitoneal closure (LPEC) versus open repair of pediatric hernias/hydrocele in a single institution.

Materials and methods

We retrospectively reviewed the medical data of children who underwent laparoscope-assisted single-needle LPEC and open repair (OR) for inguinal hernia from 2014 to 2019. Data collection included demographics, laterality of hernia, surgical time and time to follow-up. We also reviewed and analyzed the evidence of recurrence, the incidence of metachronous contralateral inguinal hernia (MCIH), and other complications.

Results

In our cohort, 961 patients in the OR group and 1098 patients in the LPEC group were analyzed retrospectively. Mean operative time was significantly shorter in the LPEC group (22.3 ± 3.5 min) than in the OR group (27.8 ± 5.9 min) for bilateral hernia repair (p < 0.001). Postoperative recurrence was 1.3% (13/1035) in the OR group and 0.5% (6/1182) in the LPEC group (p = 0.056). Iatrogenic cryptorchidism occurred statistically more frequently in the OR group than in the LPEC group (0.4% vs. 0%, p = 0.013). In addition, the incidence of MCIH was 3.7% (33/887) in the OR group and 0.3% (3/1014) in the LPEC group (p < 0.01).

Conclusion

Comparing to open technique, laparoscope-assisted single-needle LPEC provides a simple and effective option for pediatric inguinal hernia/hydrocele repair with excellent outcomes, a low incidence of recurrence, and reduced MCIH.

Should the processus vaginalis sac be opened or closed in pediatric herniotomy? A two-center cohort study

BACKGROUND

Inguinal hernia repair is one of the most common operations in children. To improve outcome, several techniques are used. However, it has not been established if the open or the closed hernia sac preparation technique is superior in (premature) neonates and older children.

METHODS

Retrospective study including all cases of inguinal hernia repair in children at two large centers. Demographic data and outcome parameters including procedure time and intra as well as postoperative complications were evaluated. To compare open vs. closed hernia sack preparation, cases with secondary open preparation were excluded and propensity score matching was performed. Regression analysis was used to determine factors affecting operative time and recurrence rate.

RESULTS

In total 2476 cases of inguinal hernia repair were identified. After exclusion of direct hernias as well as revision cases, 2257 cases were analyzed. Overall mean operative time was 25.8 min. Intraoperative complications occurred in 0.1% and. postoperative complications occurred in 3.0% of all cases, the most frequent postoperative complication being recurrence (1.7%). Closed preparation technique resulted in significantly faster procedure time and lower recurrence rates in premature neonates and older children compared to the open hernia sac preparation technique. Operative technique, prematurity, gender and training of the surgeon are highly associated with operative time, whereas operative technique is the main factor affecting recurrence rate.

CONCLUSIONS

It appears that closed hernia sack preparation is superior to open regarding speed and recurrence. This was true for premature neonates, neonates and older children. All other outcome parameters including intra- and postoperative complications were similar. Thus, we recommend to use the closed preparation technique whenever possible.

Surgical Management of Pediatric Inguinal Hernia: A Systematic Review and Guideline from the European Pediatric Surgeons' Association Evidence and Guideline Committee

INTRODUCTION

 Inguinal hernia repair represents the most common operation in childhood; however, consensus about the optimal management is lacking. Hence, recommendations for clinical practice are needed. This study assesses the available evidence and compiles recommendations on pediatric inguinal hernia.

MATERIALS AND METHODS

 The European Pediatric Surgeons' Association Evidence and Guideline Committee addressed six questions on pediatric inguinal hernia repair with the following topics: (1) open versus laparoscopic repair, (2) extraperitoneal versus transperitoneal repair, (3) contralateral exploration, (4) surgical timing, (5) anesthesia technique in preterm infants, and (6) operation urgency in girls with irreducible ovarian hernia. Systematic literature searches were performed using PubMed, MEDLINE, Embase (Ovid), and The Cochrane Library. Reviews and meta-analyses were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement.

RESULTS

 Seventy-two out of 5,173 articles were included, 27 in the meta-analyses. Laparoscopic repair shortens bilateral operation time compared with open repair. In preterm infants, hernia repair after neonatal intensive care unit (NICU)/hospital discharge is associated with less respiratory difficulties and recurrences, regional anesthesia is associated with a decrease of postoperative apnea and pain. The review regarding operation urgency for irreducible ovarian hernia gained insufficient evidence of low quality.

CONCLUSION

 Laparoscopic repair may be beneficial for children with bilateral hernia and preterm infants may benefit using regional anesthesia and postponing surgery. However, no definite superiority was found and available evidence was of moderate-to-low quality. Evidence for other topics was less conclusive. For the optimal management of inguinal hernia repair, a tailored approach is recommended taking into account the local facilities, resources, and expertise of the medical team involved.

Pediatric Inguinal Hernia Repair, Laparoscopic Versus Open Approach: A Systematic Review and Meta-Analysis of the Last 10-Year Evidence

Aim: Since the first description of laparoscopic herniorrhaphy (LH), a lot of studies have compared outcomes between LH and open herniorrhaphy (OH) with inconsistent results. We designed this study to assess outcomes between both techniques now that pediatric surgeons have enough confidence with it. Methods: We performed a systematic review and meta-analysis of articles published in the last 10 years. Results: Twenty-seven articles reporting on 91,653 patients (26,920 LH and 64,733 OH) were included. No significant differences were found in overall operative time (OT) (P = .07). Subgroup analysis revealed significantly shorter OT for LH in unilateral (-8.87 minutes, P = .03) and bilateral hernias (-16.86 minutes, P = .004), but longer in unilateral hernias in females (+7.47 minutes, P = .006). Recurrence rate was similar (odds ratio [OR] 1.05, P = .66). Less complications were reported in LH (OR 0.51, P = .03). Contralateral patent processus vaginalis average rate was 39.61% and its closure reported a significant decrease of contralateral metachronous hernia (OR 0.11, P < .00001). Conclusion: Although OH is still considered the gold standard by some authors, LH has proven to be not only as safe as OH but also to have additional advantages that should make pediatric surgeons implement it in their daily practice and not in selected cases alone.

Cost-Effectiveness of Laparoscopic and Open Pediatric Inguinal Hernia Repair

Aim: Laparoscopic inguinal hernia (IH) repair is an alternative to open surgery. A potential advantage of laparoscopic repair is prevention of contralateral metachronous hernia although some studies report higher recurrence rate. We aim to determine the cost-effectiveness of open versus laparoscopic IH repair taking into account metachronous and recurrence rates. Methods: Retrospective single-center study of children (<5 years) undergoing elective open or laparoscopic repair for a unilateral IH between February 2018 and October 2019. Ten cases in each of four groups were included (open day case, open overnight, laparoscopic day case, and laparoscopic overnight). Cases incurring a higher cost due to comorbidities or additional procedure were excluded. Patient-level information and costing system data were obtained from the hospital finance. Mean (standard deviation [SD]) procedural cost was compared for open and laparoscopic procedures. A financial model was created factoring metachronous and recurrent rates. Results: Cost of open day case repair was £1866.24 (SD: 311.15) compared with £2210.13 (SD: 391.36) for day case laparoscopic repair. For overnight repair, cost of open was £2442.82 (SD: 497.05) compared with £2585.35 (SD: 384.66) for laparoscopic. On calculating the cost-effectiveness point using the difference in metachronous and recurrence rate between the two procedures, laparoscopic is more cost-effective than open day case repair at 18.43%. For overnight repair, the difference rate is 5.84%. Conclusion: Our data suggest that based on metachronous and recurrence rates in the current literature, laparoscopic IH repair is more cost-effective than open repair for cases requiring overnight stay, whereas for day case procedures open IH repair is more cost-effective.

Large intestine as content of congenital inguinal hernia: A case report of intestinal obstruction

Introduction and importance

Hernias containing appendix, caecum and transverse colon are uncommon in contrast with usual inguinal hernias containing small intestine. The patient usually presents with inguinoscrotal swelling.

Case presentation

We present a case of a 2 months old male child presented with inguinoscrotal swelling, vomiting with abdominal distention. On Ultrasonography (USG) of the scrotum, protrusion of the abdominal cavity contents through the right inguinal canal into the scrotum of approximately 3.4 cm × 0.7 cm was found which indicates right inguinal hernia. On the opening of the hernia sac during surgical management, the appendix, caecum and transverse colon were lying inside the hernia sac. Open Herniotomy was performed and the abdomen was closed in layers. Postoperative period of the patient was uneventful.

Discussion

Congenital inguinal hernia in the child occurs mostly due to persistent processus vaginalis. History and clinical examination reveals the appearance of lump in the inguinal region or scrotum. Preoperative Ultrasonography can be used to supplement the physical examination and increase the accuracy of its diagnosis. Although the laparoscopic approach is increasingly used nowadays, open hernia repair is preferred in young children.

Conclusion

Appendix, caecum and transverse colon are unusual contents of an inguinal hernia. Open herniotomy combined with relieving of the intestinal obstruction is the treatment of choice in young children.

Risks and benefits of pediatric inguinal hernia repair: Conventional open repair vs laparoscopic percutaneous extraperitoneal closure

INTRODUCTION

Considerable debate exists regarding the benefits of laparoscopic percutaneous extraperitoneal closure (LPEC) over conventional open repair (OR). We assessed the outcomes and feasibility of LPEC compared to OR for pediatric inguinal hernia (IH).

METHODS

We retrospectively analyzed 570 children who underwent LPEC or OR. Parents decided the operative method after obtaining informed consent. Patient characteristics, operative time, complications and contralateral metachronous IH (CMIH) were compared between the groups.

RESULTS

A total of 329 children underwent LPEC and 241 underwent OR. There was no significant difference in the incidence of recurrence or testicular ascent between the LPEC and OR groups (0.3% vs 0.4%, P = 0.825, 0.3% vs 0.8%, P = 0.391, respectively). No testicular atrophy was recognized in either group. One patient with postoperative chronic inguinal pain was recognized in each group. There was no surgical site infection (SSI) in the OR group; however, the LPEC group more frequently demonstrated umbilical port site (UPS)-related complications, such as incisional hernia, minor deformity, granuloma formation, cellulitis and superficial SSI. Ten (4.1%) developed CMIH in OR; in contrast, no case of CMIH was experienced after LPEC (P < 0.001).

CONCLUSION

In conclusion, both LPEC and OR are feasible in the management of pediatric IH, because of their high success rates and low risk of complications. LPEC could be the superior procedure with respect to the prevention of CMIH. However, to maximize the merits of LPEC over OR, it is important to reduce UPS-related complications in LPEC. A longer follow-up is needed to assess male fertility in patients who receive LPEC.

The Status of Laparoscopic Inguinal Hernia Surgery in Children: A Nationwide Assessment

Inguinal hernia repair (IHR) is a common procedure in childhood. Laparoscopic IHR has been evolving for the last three decades. Although clear advantages have been shown, adaptation in Germany has been slow. We aim to study the current status of pediatric laparoscopic IHR. A survey was sent to all 89 pediatric surgical departments in Germany on current practices and preferences of open versus laparoscopic IHR. Two nationwide databases of administrative claims data from 2019 were analyzed and correlated with responses from the survey. A total of 56% of the pediatric surgical departments supplied data through the quality reports. The recall of our survey was 58% of all pediatric surgery departments. According to the pooled data, laparoscopic IHR was performed in 8.2% of all inpatients treated. Laparoscopic IHR was considered a training procedure in 48% of the departments. Five different laparoscopic techniques were described (most commonly percutaneous closure of the hernia under laparoscopic vision). The choice between open and laparoscopic IHR was mainly determined by the child’s age. Currently, only a minority of German children undergo inguinal hernia repair by laparoscopy. More training opportunities in the form of hands-on and video workshops may lead to more widespread employment of the laparoscopic technique.

Laparoscopic inguinal herniotomy: Recreating the open operation optimises outcomes

BACKGROUND

Recent evidence suggests simple laparoscopic inguinal herniorrhaphy is associated with higher rates of recurrence and testicular ascent. We instigated a standardised approach to laparoscopic inguinal herniotomy (LIH), with circumferential sac division and 'purse-string' closure (4/0 monofilament polypropylene). An active follow-up programme was pursued. We reviewed our outcomes of this technique and compared them to an open herniotomy (OIH) cohort.

METHODS

LIH patients were identified prospectively (2017-2021): OIH retrospectively from 2016. Risk factors for complications were defined: extremely to very preterm (< 32 weeks), emergency presentation with incarceration, and redo surgery for recurrence. Data are presented as median [IQR]. Comparisons used Fisher's exact and Mann-Whitney U tests: significance defined as p < 0.05.

RESULTS

192 inguinal herniae in 140 patients were included in the LIH group and 214 herniae in 179 patients in the OIH group. Groups were similar in age and gender. The LIH group had a significantly larger proportion of cases that were premature, had emergency surgery, or had redo surgery after previous OIH. Follow-up was 24.4 months [10.8-33.6] vs. 66.4 [64.5-68.5] (LIH vs. OIH). Hernia recurrence occurred in 2/192 (1.0%) vs. 4/214 (1.9%) (LIH vs. OIH), p = 0.69. There was one known case of testicular ascent after OIH but none in the LIH group.

CONCLUSIONS

Recreation of the open herniotomy laparoscopically appears to confer excellent outcomes, with low rates of recurrence despite a high proportion of patients having known risk factors. Further long-term data on rates of testicular ascent after active follow-up are required.

A dual-institutional study on first-year practice outcomes of pediatric surgeons who trained in the era of work hour restrictions

BACKGROUND

In July 2003, an 80-h work week restriction for residencies was mandated. This was met with skepticism regarding its potential impact on operative training. We hypothesized no difference in outcomes for pediatric surgeons who trained under duty hour restrictions compared to historical complication rates.

METHODS

Dual-institutional review of pediatric patients who underwent five of the most common operations (2013-2018) by first-year pediatric surgeons who trained under duty hour restrictions was performed. Tests of proportions were used to compare complication rates to published rates on data collected prior to 2003.

RESULTS

Patient mean age was 10.1 years. No significant differences (p values > 0.05) were found in laparoscopic appendectomy rates of infection, bleeding or intra-abdominal abscess compared to previously published rates. Pyloromyotomy rates of infection or duodenal perforation were not different. No differences were detected in rates of infection, recurrence or testicular atrophy for inguinal hernia repair. Umbilical hernia rates of infection, bleeding, and recurrence were also not different. There was no difference in CVC rates of hemopneumothoraces; significantly more bleeding events were detected (1.2% vs. 0.1%; p value = 0.04).

CONCLUSION

In this study, first-year complication rates of pediatric surgeons who trained under duty hour restrictions were not significantly different when compared to published rates.

Percutaneous Internal Ring Suturing (PIRS) – The Benefits of Laparoscopic Inguinal Hernia Repair

Introduction

The laparoscopic inguinal hernia repair in children using the PIRS technique is a well-established method. However, there are still opinions that this method does not bring more benefits than open surgery.

Purpose

The study aims to demonstrate the benefits of laparoscopic technique over conventional, open techniques.

Patients and Methods

We conducted a retrospective study that included children aged 0–18 treated using the PIRS technique in 2008–2016. The control group consisted of patients treated with the traditional, open method of inguinal hernia repair. A total of 276 children were qualified for laparoscopic surgery, and there were 274 patients in the control group. A full laparoscopic procedure was performed on 247 patients. Assessment of the pathology of the internal inguinal ring was done in all patients during the laparoscopic procedure. Intraoperatively 79 children had bilateral inguinal hernia diagnosed, 133 right-sided inguinal herniae, and 57 left-sided inguinal herniae. The occurrence of hernia was not confirmed in 7 children, whereas 53 patients had open contralateral patent processus vaginalis. In a case of contralateral patent processus vaginalis, the repair was performed using the PIRS method.

Results

The recurrence of the inguinal hernia was observed in 10 children in the laparoscopic group and in 5 cases in control group. The duration of the procedure was noted and compared to open inguinal hernia repair. There was a statistically shorter duration of the laparoscopic method. In the control group, there were 16 patients with a metachronous contralateral inguinal hernia.

Conclusion

The laparoscopic inguinal hernia repair was associated with a better assessment of hernia pathology, shorter operative time, and lower risk of contralateral hernia repair.

Laparoscopic versus open inguinal hernia repair in children: A systematic review

Purpose

Considerable debates exist regarding the preferable technique to repair a paediatric inguinal hernia (PIH). This systematic review aims to compare the efficacy and safety of laparoscopic herniorrhaphy (LH) and open herniorrhaphy (OH) in PIH.

Methods

The randomised controlled trials (RCTs) that compared the outcomes of LH and OH in PIH without region and language restrictions searched from the following databases: PubMed, Web of Science Database, Cochrane Library, SciELO Citation Index, Russian Science Citation Index, China National Knowledge Infrastructure, WanFang Data and China Science and Technology Journal Database.

Results

A total of 13 RCTs that involving 1207 patients included in the review. The LH displayed a shorter operative time for bilateral hernia repair (weighted mean difference = -8.23, 95% confidence interval [CI]: -11.22~-5.23, P < 0.00001), a lower complication rate (odds ratio [OR] = 0.32, 95% CI: 013-0.83, P = 0.02) along with a lower wound infection (OR = 0.14, 95% CI: 0.04-0.55, P = 0.005) and major male-specific post-operative complications (OR = 0.10, 95% CI: 0.04-0.24, P < 0.00001) and a less contralateral metachronous inguinal hernia (CMIH) incidence rate (OR = 0.09, 95% CI: 0.02-0.42, P = 0.002). No significant difference was found for unilateral operative time, time to full recovery, length of hospital stay, recurrence and hydrocele rates between the two techniques.

Conclusion

The present review reiterates that both the LH and OH techniques for the PIH repair are comparable. However, in some aspects, the LH is superior to the OH in terms of operative time for bilateral hernias, post-operative complications rate and CMIH incidence rate. Rigorously designed RCTs are anticipated to confirm the clinical effects of both LH and OH.

Laparoscopic Hernia Repair with the Extraperitoneal Approach versus Open Hernia Repair in Pediatric Inguinal Hernia: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis investigated the feasibility and effectiveness of laparoscopic hernia repair with the extraperitoneal approach in pediatric inguinal hernias.

SUMMARY BACKGROUND DATA

Inguinal hernia repair is the most common operation in pediatric surgical practice. Although open hernia repair (OHR) is a well-established procedure with good outcomes, studies have reported acceptable or even better outcomes of laparoscopic hernia repair with the extraperitoneal approach (LHRE). However, a meta-analysis comparing LHRE with OHR is lacking.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials (RCTs) and comparative studies (prospective or retrospective). Outcomes were metachronous contralateral inguinal hernia (MCIH), hernia recurrence, surgical site infection, operation time, and hospitalization length. A meta-analysis was performed, and risk ratios (RR), weighted mean difference (WMD), and 95% confidence intervals (CI) were calculated using random-effects models.

RESULTS

Five RCTs and 21 comparative studies involving 24,479 patients were included. Lower MCIH incidence (RR: 0.11, 95% CI: 0.07 to 0.17; p < 0.00001) and a trend of shorter operation time (WMD: -11.90 min, 95% CI: -16.63 to -7.44; p < 0.00001) were found in the LHRE group. No significant differences in ipsilateral recurrence hernias, surgical site infection, and length of hospitalization were found between the groups.

CONCLUSIONS

LHRE presented lower MCIH incidence and shorter operation times, with no increase in hernia recurrence, surgical site infection, or length of hospitalization. As more surgeons are increasingly becoming familiar with LHRE, LHRE would be a feasible and effective choice for pediatric inguinal hernia repair.

Laparoscopic surgery: an effective and safe surgical method of pediatric inguinal hernia repair

Purpose

Inguinal hernia (IH) repair is very commonly performed in children. While open repair (OR) is the standard approach, laparoscopic repair is increasingly used. This study was aimed to investigate safety and feasibility of laparoscopic repair of pediatric IH compared to OR.

Methods

We retrospectively enrolled 105 pediatric patients with IH repair between January 2011 and October 2019. The laparoscopic procedures performed were laparoscopic percutaneous extraperitoneal closure (LPEC), and three-port mini-laparoscopic repair (TLR). The OR was performed as per usual technique.

Results

Thirty-nine patients underwent OR, 16 LPEC, and 50 TLR. The preoperative laterality of IH was 45 patients (42.9%) on the right side, 50 (47.6%) on the left side, and 10 (9.5%) on both sides. It was, however, diagnosed postoperatively in 27 patients (25.7%) on the right side, 38 (36.2%) on the left side, and 40 (38.1%) on both sides. Of the 63 patients who presented with unilateral IH in the laparoscopic groups, 32 (50.8%) had synchronous contralateral patent process vaginalis (PPV) which were simultaneously repaired. This was significantly more common in children under 3 years of age. Operative time in unilateral or bilateral repair was significantly shorter in the laparoscopic repair groups (p < 0.001). Ipsilateral recurrence was not observed in any group. Metachronous contralateral IH occurrence was not significantly different between groups.

Conclusion

Laparoscopic IH repair may have benefit in terms of shorter operation time and diagnosis of unpredicted contralateral PPV compared to OR.

Laparoscopy is increasingly used for pediatric inguinal hernia repair

INTRODUCTION

Inguinal hernia repairs (IHR) are commonly performed by pediatric surgeons in the United States. The operative approach depends on surgeon preference with no definitive prospective studies comparing laparoscopic inguinal hernia repair (LIHR) versus traditional inguinal hernia repair (TIHR). We aim to assess current practice, hypothesizing that laparoscopy is increasingly used for pediatric IHR.

MATERIAL & METHODS

The Children's Hospital Association (CHA) Pediatric Health Information System was queried for IHRs performed between 01/01/2009 and 12/31/2018. Demographics, procedure type, hernia laterality, and cost were obtained. Patients were grouped by procedure type (laparoscopic/traditional).

RESULTS

125,249 IHRs were performed at 32 CHA hospitals during the ten-year study period. 115,782 (92.4%) were TIHR and 9467 (7.6%) LIHR. Use of laparoscopy increased 5-fold from 3% to 15% over the study period. When comparing laparoscopic to traditional IHR groups, there were more females (28.3% vs 12.6%), African-Americans (19.7% vs 14.4%), government-insured (50% vs 45.2%), younger patients (4.2 vs 4.4 years), bilateral IHRs (11.4% vs 7.9%), and higher adjusted total hospital cost ($3,791 vs $2995) in the laparoscopic group (p<0.0001, all comparisons).

CONCLUSIONS

Laparoscopy for pediatric IHR is increasing at CHA hospitals where nearly 1 in 6 children currently undergoes a laparoscopic repair. The long-term outcomes with laparoscopic repair are worthy of future study.

Re-evaluation of jumping purse-string suturing in pediatric laparoscopic hernia repair

BACKGROUND

Reported recurrence rates using jumping purse-string suturing in laparoscopic hernia repair (LH) are higher than that of intact purse-string. This study aims to compare the outcomes of LH using transabdominal jumping purse-string suturing (TJS) with those using transabdominal intact purse-string suturing (TIS) and percutaneous extraperitoneal intact purse-string suturing (PEIS).

METHODS

A total of 3340 patients from three centers who have undergone laparoscopic hernia repair from January 2016 to June 2019 were retrospectively reviewed. Of these, 1460 patients received TJS, 724 patients received TIS, and 1006 patients received PEIS. One hundred and fifty patients were excluded due to the loss of follow-up. Demographic characteristics, intraoperative findings, and postoperative complications were analyzed.

RESULTS

The hernia distribution characteristics and mean length of hospital stay were similar among the three groups (p > 0.05, p > 0.05). While the overall complication rates were similar among the three groups (0.34% in TJS vs. 0.41% in TIS vs. 0.50% in PEIS, TJS & TIS p = 0.502; TJS & PEIS p = 0.813), the incidence of intraoperative hematoma in TIS group and postoperative subcutaneous knot in PEIS group was significantly higher ((0.83% in TIS and 0.34% in TJS vs. 0.2% in PEIS, TJS & TIS p = 0.018; TJS & PEIS p = 0.163), (0% in TIS and 0% in TJS vs. 0.2% in PEIS, TJS & TIS p = 0.415; TJS & PEIS p = 0.025)). There were no differences in the recurrent rate in both unilateral and bilateral cases.

CONCLUSIONS

Transabdominal jumping purse-string suturing is not associated with a higher recurrence rate and is the recommended surgical approach.

Initial Experience with Robotic Inguinal Hernia Repair in the Adolescent Population

Purpose: There is no one standard procedure encompassing the needs and differences of the entire pediatric population for inguinal hernia repair (IHR). Several techniques can be used, including open repair, laparoscopic, and robotic-assisted laparoscopic repair. This is a report of a single pediatric hospital's experience performing robotic-assisted IHRs in an adolescent population. Methods: Robotic IHRs performed by the pediatric surgery department were prospectively captured and reviewed. The operation performed was a modified robotic transabdominal preperitoneal approach with ProGrip mesh. Results: Between January 2016 and August 2020, 11 robotic-assisted IHRs occurred. All patients were male, median weight interquartile range (IQR) was 76.6 kg (67.425-90.4 kg) and median age (IQR) was 17 years (17-18.5). All together median (IQR) total operative time was 111 (97.5-126) minutes, median (IQR) total console time was 60 (55.5-75.5) minutes. There were no complications or conversions, with all patients discharged on the day of the operation. Conclusion: This study demonstrates a safe and reliable approach to repairing inguinal hernias using robotics through a small initial case series. Robotic-assisted IHR should be considered a viable technique to optimize the surgical care of adolescents.

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.

Comparison of surgical outcomes between laparoscopic percutaneous extracorporeal closure (LPEC) and open repair for pediatric inguinal hernia by propensity score methods and log-rank test analysis

BACKGROUND

Despite a number of studies comparing laparoscopic inguinal hernia repair (LH) and open herniorrhaphy (OH), the putative advantage of LH remains controversial due to a paucity of firm evidence. We hypothesized that LH has both advantages and disadvantages compared to OH and sought to clarify them by comprehensively analyzing the retrospective data using the combination of multiple statistical methods.

METHODS

Operative data for inguinal hernia during the period from February 1999 to December 2019 were examined. The patients were assigned into two groups according to the surgical procedure: laparoscopic percutaneous extraperitoneal closure (LPEC, n = 2410) and OH (n = 2038). Operative and anesthesia times and incidence of postoperative complications were evaluated using the propensity score methods and log-rank test.

RESULTS

In comparison with OH, operative time of LPEC was longer for unilateral repair (21.59 ± 8.1 min vs 18.01 ± 8.0 min; p < 0.001) and shorter for bilateral repairs (28.55 ± 10.1 min vs 33.23 ± 11.7 min; p < 0.001), while anesthesia times were longer for both unilateral repair (57.67 ± 10.1 min vs 40.62 ± 11.9 min; p < 0.001) and bilateral repairs (65.95 ± 12.5 min vs 56.35 ± 15.1 min; p < 0.001). LPEC significantly reduced the risk of metachronous contralateral hernia (MCLH) (0.52% vs 9.29%; p < 0.001), but the recurrence rate was higher (0.21% vs 0.04%; p = 0.002) than OH. Orchiectomy due to testicular atrophy or torsion was required in 3 cases of OH (0.19%), whereas it was not seen in LPEC.

CONCLUSIONS

LPEC had a less risk of MCLH and testicular complications but was associated with a higher recurrence rate and longer anesthesia time. Propensity scoring techniques can enhance the robustness of retrospective comparisons between groups over several years of data collection, which is frequently required in pediatric surgery studies.

Single-site laparoscopic burnia for inguinal hernias in girls: comparison with open repair

BACKGROUND

Burnia is a suturless repair for inguinal hernias in girls. It is performed under laparoscopy by grabbing the sac, inverting it into the peritoneal cavity, and cauterizing. The aim of this study is to report our experience with single-site laparoscopic burnia (BURNIA) and compare them with open repair (OPEN).

METHODS

With IRB approval, pediatric female patients younger than 18 years of age who underwent inguinal hernia repair between January 2015 and December 2017 were enrolled. Medical records were retrospectively reviewed. The patients were divided into two groups, BURNIA and OPEN.

RESULTS

198 patients were included. In BURNIA, 49 patients underwent bilateral repairs, and 50 patients underwent 51 unilateral repairs (one patient had metachronous contralateral hernia). In OPEN, 27 patients underwent bilateral repairs, and 72 patients underwent 77 unilateral repairs (five patients had metachronous contralateral hernias). The mean age of BURNIA was similar to OPEN for bilateral repairs (49.1 ± 36.6 vs. 43.7 ± 26.4 months, p = 0.46), but significantly older for unilateral repairs (54.6 ± 29.8 vs. 29.0 ± 31.4, p < 0.01). The mean operation time of BUNIA was similar to OPEN for bilateral repairs (24.2 ± 7.6 vs. 22.4 ± 8.6 min, p = 0.35), but significantly longer for unilateral repairs (19.2 ± 7.0 vs, 13.6 ± 8.8 min, p < 0.01). The mean follow-up duration of BURNIA was significantly shorter than OPEN for bilateral and unilateral repairs, respectively (32.5 ± 8.8 vs. 45.4 ± 4.8 months, p < 0.01) (30.2 ± 8.8 vs. 39.1 ± 9.6 months, p < 0.01). No conversion was required in BURNIA. There were no complications and no recurrence in all patients.

CONCLUSIONS

Single-site laparoscopic burnia is technically feasible, and as safe and effective as open inguinal hernia repair.

A standardized technique of laparoscopic placement of peritoneal dialysis catheter with omentectomy and closure of patent processus vaginalis: A 3-in-1 minimally invasive surgical approach in children

BACKGROUND

Omental wrapping is a common cause for catheter failure in children on peritoneal dialysis (PD). Previous studies are conflicting in the benefits of omentectomy.

METHODS

We conducted a retrospective study comparing children who underwent PD catheter placement by a standardized laparoscopic three-in-one technique (lap3-in-1) from 2013 to 2018 versus a historical control cohort by open surgery without omentectomy. Lap3-in-1technique combined catheter placement with well-defined indication and extent of omentectomy, and closure of any patent processus vaginalis (PPV).

RESULTS

There were 33 and 32 children in the lap3-in-1 and control cohorts respectively. 4/33(12.1%) in lap3-in-1 had reoperations for catheter failures which equated 1 reoperation per 144 catheter months. No reoperations were performed in lap3-in-1 cohort for omental wrapping or inguinal hernia, compared with 13/32 (41%; p < 0.001) and 5/32 (16%; p = 0.02) in the control cohort. Kaplan Meier survival curves showed significantly longer catheter life in the lap3-in-1 cohort (p < 0.001). In multivariate analysis by the COX proportional hazards model, the lap3-in-1 approach had significantly reduced risk of reoperation for catheter failure (HR 0.11; 95% CI: 0.04-0.31; p < 0.001).

CONCLUSIONS

The lap3-in-1 technique is effective in selecting those children who would benefit from omentectomy, and avoiding a second operation for inguinal hernia which develops after PD.

LEVEL OF EVIDENCE

Treatment study, level III.

Laparoscopic iliopubic tract repair for pediatric inguinal hernia has very low recurrence: an Indian experience

Background

The aim of this study is to document results of laparoscopic iliopubic tract (IPT) repair for inguinal hernia in the pediatric age group.

Methods

Hospital records of 190 children who underwent IPT repair between January 2015 and January 2020 were analyzed retrospectively for demographic details, variations between clinical, radiological and laparoscopic diagnosis, associated pathologies, operative time, hospital stay, postoperative complications and follow-up. The internal ring was narrowed by approximating IPT to conjoint tendon using 3-0 polypropylene continuous or interrupted suture.

Results

In total, 238 IPT repairs were done under general anesthesia in 190 children aged between 1 and 17 years. 7.9% of children had phimosis, and three children had hydrocele. Three patients had undescended testis and another three IPT repairs were done in cases who presented with appendicitis. Contralateral patent processus vaginalis (CPPV) was detected at the time of laparoscopy in 18.3% of cases. Thus far, 166 children had been followed, and no recurrence was observed in any of these 96 of whom have completed more than 3 years after their surgery. However, two patients developed hernia on the contralateral side.

Conclusions

Laparoscopy is beneficial to pick up CPPV. Laparoscopic IPT repair for pediatric inguinal hernia is reproducible and safe with the least recurrence reported thus far. However, further follow-up is needed. Moreover, development of contralateral hernia needs to be investigated.