Stitch Versus Scar—Evaluation of Laparoscopic Pediatric Inguinal Hernia Repair: A Pilot Study in a Rabbit Model

Laparoscopic Sac Disconnection and Peritoneal Closure of Pediatric Inguinal Hernia

Background: Laparoscopic sac disconnection and peritoneal closure represents an alternative to open pediatric hernia repair. We performed a retrospective review of our data to evaluate this alternative method. Materials and Methods: With REB approval, a retrospective chart review of all patients who underwent laparoscopic indirect inguinal hernia repair between June 2013 and July 2016 was conducted. Primary outcome was the recurrence rate. Secondary outcomes included length of surgery, postoperative hydrocele, and perioperative complications. Data were extracted from EPIC Hyperspace onto a standardized data extraction form. Results: A total of 243 patients were included, of which 82% were males. Age ranged from 1 month to 17 years of age. A total of 322 defects were repaired. Eighty (32%) had contralateral patent processus vaginalis. Twelve (4%) patients presented with incarceration and three (1.2%) had a direct inguinal hernia defect. Recurrence rate was 0.6% (n = 2). There were no intraoperative complications. Operative time was an average of 40 and 54 minutes for unilateral and bilateral repairs, respectively. No testicular ascents, testicular atrophy, vas deferens injury, postoperative hydroceles, and wound infections were reported. Conclusion: Laparoscopic sac disconnection and peritoneal closure of pediatric inguinal hernia is a safe, feasible method with one of the lowest reported recurrence rate among the other laparoscopic methods.

Modifications of surgical techniques in laparoscopic percutaneous extraperitoneal closure of inguinal ring for childhood inguinal hernia to achieve zero recurrence and zero subcutaneous stitch granuloma

PURPOSE

To present our technical modifications of single incision laparoscopic percutaneous extraperitoneal closure (SILPEC) of the internal inguinal ring (IIR) for pediatric inguinal hernia (PIH).

METHODS

The prospectively collected data of all children diagnosed with PIH undergoing SILPEC at our center from 2016 to 2023 were reviewed and divided into two groups for result comparison: Group A: before and Group B: after the implementation of full modifications. Our modifications included using a nonabsorbable monofilament suture, creating a peritoneal thermal injury at the internal inguinal ring (IIR), employing a cannula to ensure the suture at the IIR ligates only the peritoneum, and double ligation of the IIR in selected cases.

RESULTS

1755 patients in group A and in group B (1 month to 14 years old) were enrolled. There were no significant differences regarding baseline patient characteristics between the two groups. At a median follow-up of 40 months, the rate of recurrent CIH and subcutaneous stitch granuloma (SSG) was 2.3% and 1.5% in group A vs. 0% and 0% in group B (p < 0.001). There were no hydroceles, no ascended or atrophic testis.

CONCLUSIONS

Our SILPEC technical modifications can achieve zero recurrence and zero SSG for PIH.

Addition of Transfixation Suture to Purse String Suture During Intraperitoneal Inguinal Hernia Repair Increases Peri-Hernia Sac Neck Collagen Formation

BACKGROUND

The worldwide accepted repair for indirect inguinal hernia in children is high ligation of the hernia sac with open herniotomy. However, laparoscopic pediatric inguinal hernia repair (IHR) has been gaining popularity in the last two decades. An experimental study was conducted to investigate the effects of different intraperitoneal IHR suture techniques on the collagen formation at the hernia sac neck.

METHODS

Present study was conducted on thirty-five male adult (3-6 months old) Wistar-Albino rats (260-300 g). Intraperitoneal IHR with different hernia sac neck suturing techniques (purse string suture only, transfixation suture only and purse string suture plus transfixation suture) were performed through median laparotomy using open operative techniques. Non-absorbable 2/0 braided polyester suture with 16 mm 1/2 curved round needle (Ti-cron, Covidien, MN) was used as suture material.

RESULTS

The highest collagen thickness around the suture was detected in intraperitoneal IHR with purse-string plus transfixation suture group. The collagen thickness of the intraperitoneal IHR with purse string suture only and IHR with tranfixation suture only groups were not statistically significantly different. The collagen thickness of the intraperitoneal IHR with purse string suture plus transfixation suture group was statistically significantly higher compared with the intraperitoneal IHR with purse string suture only and intraperitoneal IHR with transfixation suture only groups.

CONCLUSIONS

The combined usage of purse string suture and transfixation suture during laparoscopic intraperitoneal inguinal hernia repair further stimulates mesothelial fibrosis at the hernia sac neck compared with mesothelial fibrosis induced by purse string suture only or transfixation suture only.

Medium-Term Outcomes of the Godoy Burnia Repair: Durability of a Sutureless Laparoscopic Inguinal Hernia Repair in Girls

Background: Several methods to repair pediatric inguinal hernias utilizing a minimally invasive technique have been developed over the decades. These methods often involve passage of suture through the peritoneum at the level of the inguinal ring. We previously described the Godoy Burnia, a laparoscopic, sutureless, cautery-only inguinal hernia repair (IHR), and this follow-up study provides longer term data for this emerging surgical technique. Methods: After institutional review board approval, a single-centered retrospective review was performed of female pediatric patients with Godoy Burnia repair from 2014 to 2021. Demographics, operative details, and outcomes were reviewed. Technique: Through a single umbilical incision, a 3 mm port and camera and 3 mm Maryland dissector are placed into the abdomen. The Maryland dissector grasps the hernia sac, everts it, and brings it into the abdomen. Electrocautery is applied to allow scarring and closure of the inguinal ring. Results: Sixty-nine hernia repairs were performed on 44 patients with ages 5 days to 16 years (average 3.9 years) and weighing 2-70 kg (average 16 kg). Average follow-up was 52.8 months, and average operative times were 14/16 minutes for unilateral/bilateral repair, respectively. Twenty-two percent of hernias were found at time of another surgery and repaired. One recurrence (1.45%) in a 16-year-old patient, and 2 patients with other short-term complications. Conclusions: Godoy Burnia, a single-incision, sutureless, laparoscopic IHR in girls, is an acceptable alternative surgical technique with a low complication and recurrence rate. The longer follow-up in this study demonstrates the durability of the repair in most age groups, and decreased operative times suggest a favorable learning curve.

Paediatric laparoscopic inguinal hernia repair: Level of disconnection of peritoneal cuff - An observational study

Introduction

Inguinal hernia is a common surgical condition in children. Conventionally, the open approach for inguinal hernia repair has been considered the gold standard. However, in the past two decades, laparoscopic inguinal hernia repair has gained popularity among paediatric surgeons as an alternative to the open approach. Apart from good cosmesis and shorter stay at hospital, laparoscopy offers clear-cut advantages of visualising contralateral site and simultaneous repair if it is patent. Many techniques for laparoscopic inguinal hernia repair have been proposed. In this retrospective observational study, we are comparing outcomes between proximal and distal disconnection of hernia sac.

Materials and Methods

Ninety-five patients with inguinal hernia were studied in two groups. Group A included 50 patients in which hernia sac was disconnected from the peritoneal cuff proximal to deep inguinal ring (DIR). Group B included 45 patients in which hernia sac was disconnected distal to DIR. Various sociodemographic parameters and intraoperative findings were compared. Outcomes were analysed in terms of post-operative pain, duration of stay at the hospital and recurrences.

Results

In group A, there were 46 males and four females with mean age of 4.01 years with standard deviation (SD) of 2.96. Group B included 37 males and eight females with mean age of 5.09 years with SD of 3.56. Excess post-operative pain was observed in 33 patients in Group A with proximal disconnection of hernia sac whereas it was seen in only three patients in Group B with distal disconnection of sac. The P was 0.001 which was highly significant. The duration of stay in the hospital was more in Group A (2.36 ± 1.22 days) as compared to Group B (1.8 ± 0.66 days) with a P of 0.0076 which was significant. Hernia recurrence was seen in four out of 50 patients in Group A (8%) as compared to no recurrence in Group B. However, the difference was not significant.

Conclusion

The disconnection of hernia sac distal to DIR is associated with less post-operative pain and shorter duration of hospital stay. There is less recurrence seen in distal disconnection of hernia sac as compared to proximal disconnection; however, to achieve the level of significance, a large cohort study is required.

Reduction of recurrence by peritoneal thermal injury in laparoscopic percutaneous extraperitoneal closure of internal ring for inguinal hernia in children

PURPOSE

To evaluate the impact of peritoneal thermal injury (PTI) in the reduction of recurrence incidence in laparoscopic percutaneous extra-peritoneal closure of internal ring (LPEC) for pediatric inguinal hernia (PIH) in children.

METHODS

Medical records of patients undergoing LPEC for PIH at our center were reviewed and divided into 2 groups: Group A (period from June 2017 to December 2017)-without PTI and Group B (period from January 2018 to December 2018) with PTI. The surgical technique and the type of suture used for LPEC were the same for both groups. The outcomes of the two groups were analyzed and compared.

RESULTS

277 patients with 283 IHs in group A were compared to 376 patients with 389 IHs in group B. There were no significant differences between the two groups in terms of age, gender, uni- or bilateral hernia. At a median follow-up period of 48 months, there was no hydrocele, suture granuloma, testicular atrophy, or iatrogenic cryptorchidism in both groups. The recurrence rate in group A was 6.4%, significantly higher than 1.8% in group B (p = 0.002).

CONCLUSIONS

Our study showed that PTI in LPEC for PIH is safe and associated with a significant reduction of recurrence incidence.

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.

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.

Comparison study of three laparoscopic ligation procedures for pediatric inguinal hernia: a multicenter cohort of 5523 cases

PURPOSE

Single-site laparoscopic percutaneous extraperitoneal ligation (SLPEL) for pediatric inguinal hernia has gained popularity worldwide. However, complications associated with extraperitoneal knotting are not rare. This study evaluated the effectiveness of a modified SLPEL (M-SLPEL) to decrease adverse events associated with ligation knotting by comparing it with two other methods: classical SLPEL (C-SLPEL) and intracorporeal purse-string suturing (IPS).

METHODS

A multicenter retrospective comparative study was conducted among 5523 pediatric inguinal hernia patients. Cases were divided into three groups according to the surgical procedure: the M-SLPEL, C-SLPEL, and IPS groups. Data describing the clinical characteristics, operative time, and complications were collected.

RESULTS

All procedures were performed uneventfully. There were no significant differences in the age at operation (mean 2.62 ± 1.38 years). The operative time was shorter in the M-SLPEL group both for unilateral hernias (12.5 ± 1.8 min in C-SLPEL, 11.7 ± 1.3 min in M-SLPEL, and 17.6 ± 2.9 min in IPS) and for bilateral hernias (15.1 ± 2.1 min, 14.6 ± 1.7 min, and 23.9 ± 2.3 min, respectively). The overall incidence of adverse events in the inguinal region was 0% for M-SLPEL, 2.2% for C-SLPEL, and 0.5% for IPS. All patients were followed up for 12-93 months (mean 54 months). Recurrence occurred in 8 cases in the C-SLPEL group, 1 case in the M-SLPEL group, and 8 cases in the IPS group, with no significance between groups. No scrotal hematoma, testicular atrophy, or iatrogenic cryptorchidism occurred in any group.

CONCLUSION

The M-SLPEL procedure has time-consumption efficiency equivalent to that of C-SLPEL and even fewer adverse events in the inguinal region than IPS and C-SLPEL.

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.

Long-term absorbable versus non-absorbable suture in laparoscopic percutaneous extraperitoneal closure of internal ring for inguinal hernia in children

AIM

To compare the results of using long-term absorbable (LTAS) versus non-absorbable suture (NAS) in laparoscopic percutaneous extraperitoneal closure of internal ring (LPEC) for indirect inguinal hernia (IH) in children METHODS: Prospectively collected data from children undergoing LPEC for IH at our center were retrospectively reviewed to compare group A repaired with NAS (2.0 monofilament polypropylene or braided polytetrafluoroethilene) to group B repaired with LTAS 2.0 polydioxanone.

RESULTS

481 patients with 499 IHs in group A were compared to 277 patients with 283 IHs in group B. There were no significant differences in terms of age, bodyweight and laterality of IH between the two groups. At a median follow up period of 30 months, the incidence of suture knot reaction (SKR) and hernia recurrence were 3.1% and 1.0% in group A vs. 0% and 6.4% in group B with p = 0.002 and p<0.001, respectively. Monofilament NAS was associated with a low rate of both recurrence and SKR.

CONCLUSIONS

LPEC repair for pediatric IH using LTAS is associated with no SKR but a higher recurrence rate compared to NAS. Monofilament NAS such as Prolene could be a good choice in LPEC because of its low rate of both recurrence and SKR.

Recurrence after laparoscopic high ligation in adolescents: A multicenter international retrospective study of ten hospitals

PURPOSE

Inguinal hernia repairs are among the most common operations performed by pediatric surgeons. Laparoscopic high ligation is a popular technique, but its recurrence rate in adolescents is unknown. We hypothesized that recurrence after laparoscopic high ligation in adolescents would be similar to open repair (1.8%-6.3%).

METHODS

We evaluated adolescent patients (12-18 years old at the time of surgery) who underwent laparoscopic high ligation across eleven hospitals. At least six months postoperatively, they were contacted by telephone for follow-up. Variables analyzed included demographics, operative details, recurrence, and other complications.

RESULTS

A total of 144 patients were enrolled. One hospital (n=9) had a recurrence rate of 44.4%, compared to 3.0% (4/135) for the other hospitals. By accounting for 50.0% of recurrences, it represented a statistical outlier and was excluded, leaving 135 patients for analysis. The median age was 14 years, and 63.7% were male. Recurrence with the excluded center was 5.6% (8/144). Use of absorbable suture (OR 42.67, CI 4.41-412.90, p<0.01) and braided suture (OR 12.10, CI 1.54-95.25, p=0.02) was weakly associated with recurrence. Recurrence was not significantly different from published results.

CONCLUSION

Laparoscopic high ligation of adolescent inguinal hernias has a recurrence rate similar to open repair when performed by experienced surgeons.

TYPE OF STUDY

Prognosis study (retrospective study) LEVEL OF EVIDENCE: Level II.

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.

Laparoscopic Repair of Pediatric Inguinal Hernia: Disconnection of the Hernial Sac Versus Disconnection and Peritoneal Closure

Background/Purpose: Many techniques have been described for the treatment of pediatric inguinal hernia (PIH). Some authors emphasized the importance of disconnecting the sac, to create a scar, and to close the peritoneum mimicking the open approach. Others stated that peritoneal disconnection alone is enough for treatment of PIH regardless of the size of the internal ring. In this study, we compare the short-term results of laparoscopic disconnection of PIH sac versus disconnection and peritoneal closure. Patients and Methods: The study was carried from March 2016 to March 2017, on 34 patients with 40 PIH. Patients were randomly divided into two groups: group A, subjected to laparoscopic hernia sac disconnection and group B, subjected to laparoscopic hernia sac disconnection with peritoneal closure. Both groups were compared regarding the operative details, including complications and conversion, postoperative complications and recurrence. Results: Group A included 20 hernias in 15 patients, whereas group B included 20 hernias in 19 patients. The age ranged from 1 to 23 months. In group A, the mean operative time (OT) was 34.6 and 39.4 minutes, for unilateral and bilateral cases, respectively, whereas in group B, it was 45.1 minutes for unilateral cases and 65 minutes for 1 bilateral case. The OT was significantly shorter in group A for unilateral cases. There was no conversion and no intraoperative complications. Three recurrences occurred in group A (15% of hernias/20% of cases) with no recurrences in group B; difference was statistically insignificant. All 3 recurrences occurred in hernias with an internal ring diameter (IRD) >10 mm. Hospital stay was statistically shorter in group B. Conclusion: Both laparoscopic sac disconnection with internal ring closure and sac disconnection only are safe and effective treatments of PIH. However, the latter technique is not recommended for cases with IRD >10 mm because of the unacceptable high recurrence with rings >10 mm.

Modified percutaneous internal ring suturing with peritoneal injury in children: matched comparison to open hernia repair

BACKGROUND

The aim of this study was to elucidate the outcomes of percutaneous internal ring suture (PIRS) technique for inguinal hernia repair augmented with thermal peritoneal injury compared to open inguinal hernia repair (OHR) in a large population of contemporary pediatric patients. Thermal injury with PIRS has been shown to reduce recurrence in animal models and is increasingly being incorporated into clinical practice.

METHODS

Retrospective review of all PIRS procedures and OHR between Jan-2017 to Sept-2018 was performed. Data regarding patient characteristics, characteristics of the hernia, operative details, postoperative complications, and recurrence were collected. Non-parametric tests were used and p < 0.05 was regarded as statistically significant. 1:1 Propensity score matching was performed using "nearest-score" technique. Matching was done based on age, sex, follow-up time, side of hernia, repair of contralateral hernia, and number of additional procedures.

RESULTS

90 modified PIRS patients were matched to 90 OHRs. Patient demographics, hernia characteristics, and follow-up time were similar between the two groups after matching. There were no differences in recurrence rates (1 vs. 3 in OHR and PIRS, respectively, p = 0.6), complication rates (1 vs. 4 in OHR and PIRS, respectively, p = 0.4), and OR time [44.5 vs. 43 min in OHR and PIRS, respectively, p = 0.8]. There were no intraoperative complications for either technique. For OHR, laparoscopic look was performed in 23%. When successful, it revealed a contralateral PPV (patent processus vaginalis-PPV) in 41% of cases (9.4% of all OHR), all of which were repaired. For the PIRS procedures, a contralateral PPV was found in 25.6%, all of which were repaired. In the unmatched population, OHR had a metachronous hernia rate of 1.8%, none of whom had the contralateral PPV repaired at the original procedure.

CONCLUSIONS

PIRS with peritoneal injury has comparable efficacy and good safety compared to OHR. Recurrence and complication rates should further improve with increasing experience. Future studies should elucidate long term outcomes.

Needlescopic assisted internal ring suturing; a novel application of low-cost home-made instruments for pediatric inguinal hernia repair

BACKGROUND

Congenital inguinal hernia (CIH) is a commonly performed surgical procedure in infants and children. Single port laparoscopic hernia repair using percutaneous internal inguinal ring (IIR) suturing procedure is a widely employed technique for indirect inguinal hernia repair in children. The majority of extracorporeal techniques use extracorporeal knotting and burying the knot subcutaneously. This may result in many drawbacks. The aim of this multicenter study is to introduce a new technique for pediatric inguinal hernia repair using only needles without any laparoscopic instruments.

PATIENTS AND METHODS

This is a multicenter study which was conducted at Pediatric Surgical Departments of Al-Azhar, Mansoura, Alexandria and Tanta Universities during the period from January 2015 to June 2017. 314 patients with CIH underwent Needlescopic Assisted Internal Ring Suturing (NAIRS) after cauterization of the hernia sac at its neck. The main outcome measures were: feasibility, safety of the technique, operative time, recurrence rate, hydrocele and cosmetic results.

RESULTS

A total of 314 patients with CIH were corrected by NAIRS. They were 232 males and 82 females. The mean age was 28.12 ± 1.3 months (range 6-120 months). The mean operative time was 12.6 ± 1.7 min (range 8-15 min) for unilateral cases and 18.6 ± 1.7 min (range 14-20 min) for the bilateral repairs. All cases were completed laparoscopically without major intraoperative complications. No recurrence was detected in this study. No wound complications or umbilical hernias developed. Hydrocele occurred in five males (2.16%), without detection of testicular atrophy or iatrogenic ascent of the testis.

CONCLUSION

This preliminary study showed that NAIRS after cauterization of the neck of the hernia sac in infants and children is safe, feasible, reproducible with excellent cosmetic results.

Experience with peritoneal thermal injury during subcutaneous endoscopically assisted ligation for pediatric inguinal hernia

BACKGROUND

Subcutaneous endoscopically-assisted ligation (SEAL) for pediatric inguinal hernia repair has gained in popularity although variations in techniques exist. Peritoneal scarring by thermal injury has been described as an adjunct. We explored the hypothesized inverse-correlation between peritoneal scarring and recurrence after SEAL.

METHODS

We conducted a single-center retrospective review of all patients <18years old undergoing SEAL between 2010 and 2016 (REB-20172727). Demographics and outcomes were investigated. Univariate and multivariable logistic regressions were performed to evaluate the association between peritoneal scarring and recurrence.

RESULTS

We identified 272 patients. Median age was 3years, 35% were female, and 19% were born premature. Median follow-up was 30months, ≥1 visit/patient. Bilaterality was noted in 35%. There were no reported cases of metachronous hernia, vas injury, testicular atrophy or chronic pain, and recurrence rate was 4.6%. Prematurity, unilateral repair, incarceration, and suture-type (Ti-Cron® vs. Ethibond®) had significant correlation with recurrence on univariate analysis (p<0.25). Surgeon experience did not. Peritoneal scarring, performed in 195 cases (72%), was not predictive of recurrence (adjusted OR=0.87, p=0.830) on multivariable analysis.

CONCLUSION

The rate of complications with SEAL compares favorably to published data. Thermal injury was not associated with improved recurrence rates. The benefits of peritoneal scarring may not outweigh the risks.

LEVEL OF EVIDENCE

III - Retrospective Case-Control Study.

Inguinal Hernia

Laparoscopy is a safe and effective technique in the repair of inguinal hernias. This article describes the different laparoscopic herniorrhaphy technique, as well as controversial topics, such as premature infants, contralateral repair, and incarcerated hernias.

Laparoscopic Pediatric Inguinal Hernia Repair: A Pilot Study in a Novel Guinea Pig Animal Model

BACKGROUND

The purpose of this study was to compare different techniques for pediatric laparoscopic inguinal hernia repair. We hypothesize that the amount of dissection performed at the internal ring, with or without division of the peritoneum, will impact healing and thus long-term success of the repair.

METHODS

Following the Institution's Animal Care and Use Committee approval (708024-4), 20 Hartley guinea pigs underwent laparoscopic repair of their natural open internal rings. The guinea pigs were divided equally into four surgical groups: intracorporeal suture repair (IS), hernia dissection and division with intracorporeal suture (DDIS) repair, subcutaneous endoscopically assisted ligation (SEAL), and Yueng (HOOK) repair. After a 6-week survival period, a necropsy was performed. Repairs were evaluated and tested under pressures up to 30 mmHg. The suture was then removed to assess primary healing. Experimental data were analyzed using chi-square test.

RESULTS

There were no perioperative or postoperative complications. On initial evaluation, before suture removal, repair integrity was as follows: 5/10 IS, 10/10 DDIS, 7/10 SEAL, and 7/10 HOOK (P = .09). After suture removal, repair integrity was as follows: 3/10 IS, 10/10 DDIS, 5/10 SEAL, and 6/10 HOOK (P = .01).

CONCLUSION

Overall, dissecting and dividing the sac with intracorporeal suture (DDIS) closure had the best outcome. This method appears to best replicate standard open high ligation.

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.

Percutaneous internal ring suturing is a safe and effective method for the minimal invasive treatment of pediatric inguinal hernia: Experience with 250 cases

BACKGROUND/PURPOSE

Percutaneous internal ring suturing (PIRS) is a minimally invasive method for repair of pediatric inguinal hernia. In this study we report our experience with PIRS.

METHODS

All children >10kg presenting to our institute between June 2013 and March 2015 with a diagnosis of indirect inguinal hernia or communicating hydrocele underwent laparoscopic repair using PIRS technique. Patients' gender, age at surgery, side of inguinal hernia/communicating hydrocele at diagnosis, peroperative findings, surgical and anesthesia times plus follow-up findings were collected.

RESULTS

Two-hundred thirteen patients underwent 250 procedures. Inguinal hernia or communicating hydrocele was diagnosed on the right side in 113 (53.1%), the left side in 75 (35.2%) and bilaterally in 25 patients (11.7%). Contralateral hernia was found in 35 patients (16.4%). Mean surgery time was 14.3min for unilateral and 20.4min for bilateral PIRS, and mean anesthesia time was 33.6min for unilateral and 39.1min for bilateral PIRS. Average follow-up time was 9.6months. Recurrence was seen in 3 (1.4%) and complications in 6 patients (2.8%).

CONCLUSION

PIRS is a simple, safe and effective method for the treatment of inguinal hernia and communicating hydrocele in children.

Non-absorbable sutures are associated with lower recurrence rates in laparoscopic percutaneous inguinal hernia ligation

INTRODUCTION

Laparoscopic hernia repair with percutaneous ligation of the patent processes vaginalis is a minimally invasive alternative to open inguinal herniorrhaphy in children. With the camera port concealed at the umbilicus, this technique offers an excellent cosmetic result. It is also faster than the traditional laparoscopic repair with no differences in complication rates or hospital stay. The goal of this study was to describe a series of consecutive patients, emphasizing the impact of suture materials (absorbable vs. non-absorbable) on hernia recurrences.

METHODS

A retrospective review was performed of consecutive transperitoneal laparoscopic subcutaneous ligations of a symptomatic hernia and/or communicating hydrocele by 4 surgeons. Patients > Tanner 2 or with prior hernia repair were excluded. The success of the procedure and number of sutures used was compared between cases performed with absorbable vs. non-absorbable suture. Risk factors for surgical failure (age, weight, number of sutures used, suture type) were assessed with logistic regression.

RESULTS

94 patients underwent laparoscopic percutaneous hernia ligation at a mean age of 4.9 years. Outcomes in 85 (90%) patients with 97 hernia repairs at a mean of 8 months after surgery revealed 26% polyglactin vs 4% polyester recurrences (p = 0.004) which occurred at mean of 3.6 months after surgery, Table 1. Repairs performed with non-absorbable suture required only 1 suture more often than those performed with absorbable suture (76% vs 60%, p = 0.163). Logistic regression revealed suture type was an independent predictor for failure (p = 0.017). Weight (p = 0.249), age (p = 0.055), and number of sutures (p = 0.469) were not significantly associated with recurrent hernia.

DISCUSSION

Our review of consecutive hernia repairs using the single port percutaneous ligation revealed a significantly higher recurrent hernia rate with absorbable (26%) versus non-absorbable (4%) suture. This finding remained significant in a logistic regression model irregardless of number of sutures placed, age, and weight. Though the authors acknowledge the drawback of the potential for learning curve to confound our data, we still feel these findings are clinically important as this analysis of outcomes has changed our surgical practice as now all providers involved perform this procedure with exclusively non-absorbable suture. We thus suggest that surgeons who perform this technique, especially those newly adopting it, use non-absorbable suture for optimal patient outcomes.

CONCLUSIONS

Recurrent hernia after laparoscopic percutaneous hernia ligation was significantly lower in repairs performed with non-absorbable suture. Based on this data, we recommend the use of non-absorbable suture during laparoscopic ligation of inguinal hernias in children.

"Double N": Evolution of the Surgical Technique for Laparoscopic Herniorrhaphy After 10-Year Experience in a Single Center

INTRODUCTION

We describe our experience with the use of a modified technique for laparoscopic internal inguinal ring closure (peritoneal incision and double "N" stitch placement). We evaluate the technique in terms of feasibility, efficacy, and safety.

MATERIALS AND METHODS

From November 2003 to March 2014 we performed 1700 herniorraphies by laparoscopy. We selected 123 patients treated with the "double N" technique by the same surgical team, and we reviewed their notes analyzing demographic data, operative times, intra- and postoperative complications, and recurrence rate. The technique used is a modification of the Schier technique. Our technique consists of a partial lateral peritoneal 180° incision around the internal inguinal ring and in the placement of a double stitch. The first stitch is used to approximate the muscles with the inguinal ligament, and the second one is used to close the peritoneum above them.

RESULTS

The female to male ratio was 22:101. Mean age at surgery was 4.3 years (range, 1 month-12 years). Mean operative time was 30 minutes (range, 20-50 minutes). There were 60 bilateral cases. There were no intraoperative complications. Two patients had reactive hydrocele treated conservatively, and 1 patient developed umbilical infection. We did not identify any recurrence.

CONCLUSIONS

Our early results suggest that the "double N" laparoscopic technique to close the internal inguinal ring in children is safe and efficient. We therefore suggest using this approach in children with a patent internal inguinal ring of >1 cm. The recurrence rate is low, but it should be better assessed by studies with longer follow-up.