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

Analysis of Techniques in Laparoscopic Inguinal Hernia Repairs across Pediatric Age Groups: EUPSA Trainees of European Pediatric Surgery Survey

AIM

 This survey analyzed techniques in laparoscopic inguinal hernia repair (LIHR) across pediatric age groups.

MATERIALS AND METHODS

 Data were collected through an online survey for pediatric surgeons, comprising of 38 questions, conducted by the European Pediatric Surgeons' Association (EUPSA) Trainees of European Pediatric Surgery (TEPS) LIHR Working Group.

RESULTS

 The survey was completed by 183 surgeons from 22 countries. Seventy-seven percent of respondents had performed LIHR at least once. Regarding preferences about the patient's gender, 7% respondents perform LIHR only in selected females, 9% routinely in females, 15% in both genders with age/weight restrictions, 24% routinely in both genders, 31% in selected cases, and 14% never perform LIHR. Percutaneous internal ring suturing (PIRS) was the preferred technique in all age groups, with totally extraperitoneal and transabdominal preperitoneal repairs preferred by 9% in adolescents. The majority (59%) repaired a contralateral patent processus vaginalis if present. Hydro-dissection (21%) and additional intra-abdominal instruments (42%) were preferred more often for male patients. The distal hernia sac was left intact by most respondents (92%). Responses regarding recurrence rates varied: 40% responded that LIHR had recurrence rates comparable to open surgery, whereas 10% reported increased recurrences and hence limited its use, and 10% consider that slightly increased recurrences are outweighed by lower complication rates associated with laparoscopic methods and thus continue LIHR.

CONCLUSIONS

 PIRS is the preferred choice for pediatric LIHR. Surgical techniques vary and are influenced by patient gender and age. The survey gives insights into demographics, case selection, and approaches among pediatric surgeons with regard to LIHR.

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.

Construction and validation of a predictive model for the risk of contralateral patent processus vaginalis in children with unilateral inguinal hernia or hydrocele

To develop a nomogram model for predicting contralateral patent processus vaginalis in children with unilateral inguinal hernia or hydrocele. A retrospective analysis was conducted on 259 children with unilateral inguinal hernia or hydrocele who underwent laparoscopic surgery at the Southern Hospital of Southern Medical University from January 2021 to December 2023. The patients were randomly divided into a training set (n = 207) and a validation set (n = 52) in an 8:2 ratio to analyze the characteristics of CPPV. Multivariate logistic regression analysis was used to screen for independent risk factors for CPPV, and a nomogram prediction model was constructed. The predictive ability, calibration, and clinical net benefit of the model were evaluated by plotting receiver operating characteristic (ROC) curves, calibration curves (HL), and clinical decision curves (DCA). Among children under 1 year old, the laparoscopic exploration revealed a CPPV incidence rate of 55.17%. The incidence rates for children aged 2-10 years ranged from 29.03 to 39.13%, and the incidence rate for children aged 11-14 years was 21.21%. Multivariate logistic regression analysis showed that age (OR = 0.9, 95%CI 0.82-0.99, P = 0.035) and female gender (OR = 2.42, 95%CI 1.21-4.83, P = 0.013) were independent risk factors for CPPV, and the incidence of CPPV decreased with age. The area under the ROC curve (AUC) for the training set of the constructed model was 0.632, and the AUC for the validation set was 0.708. The Hosmer-Lemeshow goodness-of-fit test indicated good model fit (training set P = 0.085, validation set P = 0.221), and the DCA curve suggested good clinical benefit.The nomogram model developed in this study demonstrates good clinical value. Children with unilateral inguinal hernia or hydrocele who are younger in age and female gender should undergo careful intraoperative exploration for the presence of CPPV. What is Known: • The probability of developing inguinal hernia in children with CPPV is 11%-25%, and redo surgery can increase surgical risks and financial burden. • The risk factors of unilateral inguinal hernia combined with CPPV are controversial. What is New: • Age and female gender are independent risk factors for CPPV. • A nomogram prediction model was constructed to provide a theoretical basis as well as an assessment tool for preoperative evaluation of whether children with unilateral indirect inguinal hernia are susceptible to CPPV.

Single-Port Laparoscopic Extraperitoneal Repair of Pediatric Inguinal Hernias and Hydroceles by Using Hernia Crochet Needle With a Cannula

PURPOSE

Numerous modifications laparoscopic techniques have mushroomed in recent years. Here we describe a modified technique of extracorporeal ligation of processus vaginalis in children using a hernia crochet needle with a cannula.

METHODS

Processus vaginalis repair was carried out on patients diagnosed with inguinal hernia or hydroceles using this novel technique between June 2021 and June 2022. The processus vaginalis was closed extracorporeally using a hernia crochet needle with a cannula. In the presence of patent processus vaginalis, the same procedure would be performed on the contralateral side. The primary outcomes was the safety and efficiency of this modified procedure, and the secondary outcomes was the post operative complications.

RESULTS

A total of 212 (165 inguinal hernia and 47 hydroceles) children were corrected by this novel technique. The mean operation time was 27.49 min for unilateral inguinal hernia cases and 36.55 min for bilateral cases. The unilateral hydrocele median operation time was 27.83 min and that for the bilateral cases was 37.30 min. During the mean of 10.92 months of follow-up, there was only a boy subject to a metachronous contralateral occurrence of hernia 10 months after surgery, and no other complications (knot reactions, testicular atrophy, postoperative hydrocele or iatrogenic) have been observed yet.

CONCLUSION

This study shown a unique procedure with using a hernia crochet needle with a cannula to be simple, safe, and effective in managing inguinal hernias and hydroceles in the pediatric population.

Benefits of Contralateral Patent Processus Vaginalis Closure During Laparoscopic Surgery for Inguinal Hernia in Female Children

After more than a decade, an accurate description of the current state of pediatric inguinal hernia repair still an issue of contention. Improvement of techniques together with patient-entered intervention that account for the experiences related to individual disease characteristics have become an important factor of which the surgeon must be aware. Therefore, the aim of this study is to analyze a potential treatment for metachronous contralateral inguinal hernia (MCIH) in children during laparoscopic assisted percutaneous internal inguinal ring suturing (PIRS). In a prospective clinical study, carried out at the University Clinic for Pediatric Surgery in Skopje, Republic of North Macedonia, we analyzed the data from 49 female children, aged 1-14 years old, with clinically diagnosed congenital inguinal hernia treated via PIRS. The position of hernias on the right side was 29 (59.2%) on the left side was 19 (38.8%) and on both sides was 1 (2.0%). With intraoperative assessment, it was determined that in 33 (67.3%) participants there was no presence of a hidden hernia, while in 16 (32.7%), there was indeed the presence of a hidden hernia. Of the hidden hernias determined laparoscopically [16 (100%)], 8 (50%) were left and right hidden hernias, all treated laparoscopically. The PIRS technique is a procedure where the basic advanced treatment is exploration. This also included the adequate treatment of other pathologies, such as the prophylactic closure of a contralateral patent processus vaginalis with simultaneous treatment as there is the potential for hernia in future, therefore reducing the number of metachronous inguinal hernias.