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

Percutaneous Internal Ring Suturing for the Minimally Invasive Repair of Congenital Inguinal Hernia in Neonates: A Retrospective Cohort Study

Introduction Inguinal hernia (IH) repair is among the most frequently performed surgical operations in children. While open herniorrhaphy has been the gold standard surgical method of choice, the popularity of laparoscopic repair has sharply risen over the past two decades. Although a wide range of literature on the use of laparoscopy for IH repair in children exists, data regarding neonates, an especially delicate group of children, is limited to only a few studies. This study aims to evaluate the surgical, anaesthetic, and follow-up data of term neonates undergoing percutaneous internal ring suturing (PIRS) for IH repair in order to determine if it is a viable option for this specific patient population. Materials and methods This single-centre retrospective cohort included all children who underwent PIRS for IH repair during an 86-month period between October 2015 and December 2022. Patients' gender, gestational age at birth, age and weight at surgery, side of IH at diagnosis, per-operative findings (presence of contralateral patent processus vaginalis (CPPV)), surgical time, time under anaesthesia, follow-up time, and follow-up findings were collected from an electronic database and analysed. The primary outcome measures were surgical time, rate of recurrence, and presence of CPPV and the secondary outcome measures were anaesthesia time and the rate of complications. Results During the study period, 34 neonates (23 male and 11 female) underwent laparoscopic repair for IH using the PIRS technique. Average age and weight at surgery were 25.2 ± 3.2 (20-30) days and 3530.4 ± 293.6 (3012 - 3952) gm, respectively. IH was detected on the right side in 19 (55.9%), on the left side in 12 (35.3%), and bilaterally in three (8.8%) patients at their presenting physical examination. Nine patients (26.5%) were found to have CPPV perioperatively, which were all repaired simultaneously. The average surgical time was 20.3 ± 4.5 minutes for unilateral and 25.8 ± 4.0 minutes for bilateral IH repair (p<0.01). On the contrary, the average time under anaesthesia was 33.2 ± 4.5 minutes for unilateral and 33.5 ± 4.9 minutes for bilateral IH repair, but the difference was not statistically significant (p>0.05). No early postoperative complications were observed. The average follow-up time was 27.6 ± 14.4 (range: 3-49) months. Recurrence was seen in one patient (2.9%) and umbilical incision granuloma was observed in two (5.9%) patients. Conclusion Surgical times, anaesthesia times, complication rates, recurrence rates, and rate of CPPV in neonates undergoing PIRS are similar to those in older children and comparable to those of open herniorrhaphy and other laparoscopic techniques. Despite the suspicion that the rate of CPPV would be higher in neonates, we found that it is similar to that in older children. We conclude that PIRS is a viable option for the minimally invasive repair of IH in neonates.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Transumbilical Single-Site Laparoscopic Intraperitoneal Closure of the Internal Inguinal Ring for Pediatric Inguinal Hernia

BACKGROUND

A new novel technique for pediatric inguinal hernia (PIH) repair, namely, transumbilical single-site laparoscopic intraperitoneal closure (TUSLIC) of the internal inguinal ring (IIR) with a single instrument, was introduced. The short-term follow-up of TUSLIC for PIH was compared with that of transabdominal multiple-site laparoscopic extraperitoneal closure (TAMLEC) for PIH.

METHODS

Descriptive variables, perioperative clinical features, and short-term outcomes were retrospectively analyzed and compared between the patients who underwent TUSLIC and those who underwent TAMLEC.

RESULTS

In total, 289 patients were enrolled in this study. Of these, 190 patients received TUSLIC, and 99 patients received TAMLEC. The descriptive variables (including sex, age, weight, and preoperative diagnosis of patients) were comparable between the two groups (P-values were 0.12, 0.71, 0.69, and 0.23, respectively). The mean operative times for unilateral hernia repair and bilateral hernia repairs in TAMLEC group were significantly less than those in TUSLIC group (P < 0.01). The values of surgical site infection, umbilical bleeding, testicular atrophy, iatrogenic ascent of the testis, and secondary hydrocele were not significantly different between the two groups. There were no suture granulomas, and recurrence occurred in TUSLIC group, though at a significantly lower rate than in TAMLEC group (P < 0.05).

CONCLUSIONS

TUSLIC is a feasible, safe, and reliable minimally invasive method for PIH. Compared with TAMLEC, TUSLIC has the advantages of minimized complications and a low recurrence rate.