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Laparoscopic Repair of Inguinal Hernia in Children. An Endless Debate

Khalid K. Sabet Al Ali, Mohamed E Hassan

Department of Pediatric Surgery, Al Qassimi Hospital, Sharjah, United Arab Emirates

 

Correspondence

Khalid K. Sabet Al Ali

Al Qassimi Hospital

P.O.Box 3500,Sharjah,United Arab Emirates

Tel: +97165188888

Fax: +97165387200

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Introduction

Inguinal hernia repair is one of the most frequently performed pediatric surgical operations. Unresolved debate still exists regarding the benefit of using laparoscopy over openrepair. The aim of this study was to retrospectively analyze the files of all children who underwent inguinal herniotomy, open and laparoscopic, in a single pediatric surgery center in UAE, to compare both procedures and to conclude which procedure is more feasible.

Patients and method

The study was a retrospective study conducted in the Pediatric Surgery Department, Al Qassemi Hospital, Sharjah, UAE between January 2010 and December 2012. File review was done by an independent reviewer for all cases who had inguinal herniotomy during this period whether open orlaparoscopic.

Results

A total of 320 cases of inguinal herniotomy, 120 laparoscopically (LH) versus 200 open (OH). Mean age for LH was 54 month versus 32 months for OH. In LH 12.5% wereoperated bilaterally (13 male, 2 female) versus 9% in OH (18 male). Mean operative time in LH (unilateral only) was 24 minutes versus 19 minutes in open group.  In LH there was one case (0.8%) of internal ring hematoma due to injury to inferior epigastric vessels where bleeding stopped spontaneously; there were no intraoperative complications in the open group. Follow up period ranged from 8 months to 2 years.  There was no recurrence in the OH group, however the LH had one recurrent case (0.8%) which was a sliding hernia of urinary bladder. There was one case of ascending testis (0.5%) in the open group.

Conclusion

Our preliminary results for laparoscopic inguinal herniotomy in children above one year show comparable results to open technique in the short term follow up. Laparoscopic technique offers visualization of the opposite side. We will conduct a prospective study with longer follow up and younger age group to have more accurate validated data.

Keywords:  laparoscopy, inguinal hernia, children



Introduction

Hernias and hydrocele are common conditions in infancy and childhood, and inguinal hernia repair is one of the most frequently performed pediatric surgical operations [1].

Unresolved debate still exists regarding the benefit of using laparoscopy over open inguinal hernia repair even among laparoscopic surgeons. Although inguinal hernia repair is widely performed in every pediatric surgery department, the use of laparoscopy has not gained wide acceptance due to the benefits of open repair regarding lower morbidity, good cosmetics, and lower rates of recurrence [2].

A randomized single-blinded study has shown that laparoscopic inguinal hernia repair was less painful to the patients and results in earlier recovery and better wound cosmetics. It also allowed contralateral hernias to be identified and repaired at the same time [3]. Laparoscopic inguinal hernia repair is becoming increasingly popular in pediatric patients [4], however, a high recurrence rate remains a concern [5]. The aim of this study was to retrospectively analyze the files of all children who underwent inguinal herniotomy, open and laparoscopic, in a single pediatric surgery center in United Arab Emirates (UAE) , and to compare both procedures from several aspects to conclude which procedure is more feasible to be practiced.

Patients and methods

The study was a retrospective comparative study conducted in Pediatric Surgery Department, Al Qassemi Hospital, Sharjah, UAE between January 2010 and December 2012. File review was done by an independent reviewer for all cases who had inguinal herniotomy done during this period either open or laparoscopically.

All patients 1 year old and below were done open. Cases above 1 year of age were done laparscopically, unless parents opted for open technique. The following data was collected: age, side, gender, type of surgery, intraoperative complications, time of surgery, length of postoperative hospital stay, postoperative complications, length of follow up and recurrence rate.

The data were statistically analyzed by using SPSS 17. Chi square and t tests were used to analyze the data. P < 0.05 was considered as significant difference between the two groups.

Surgical technique for laparoscopic herniotomy

After general anesthesia, a 5 mm trocar was inserted in the umbilicus with open technique. After insufflation (8-12 mm Hg), 5 mm 30 degree camera was inserted in the umbilical port. Two stab incisions were done in the right and left side of the umbilicus in the mid-clavicular lines after infiltration with local anesthetic. A 3 mm needle holder and 3 mm Maryland dissector were inserted directly through the stab incisions without trocars under direct vision. 3/0 non-absorbable stitches were used in all cases (suture length was adjusted to 8 cm).

If there was patent processus vaginalis in the contralateral side, it was closed simultaneously. Purse-string stitch was applied starting just medial to the vas deference and directed laterally avoiding damage to the vas deference, testicular vessels and inferior epigastric vessels. We grasp the peritoneum over these structures to make it taught to avoid damage to underlying structures. Tightness of the purse-string stitch was assured by absence of any gas leak into the scrotum. At the end of the procedure, the gas was evacuated from the peritoneal cavity, the umbilical defect closed in layers and the skin approximated with glue.

Results

In total, 320 cases of inguinal herniotomy were done during the review period, 200 open (OH) and 120 laparoscopic (LH). The age range for LH group was 12 - 144 months (mean 54 months) and 1 month - 144 month for OH group (mean 32 months).

In LH group 15 cases (12.5%) were bilateral (13 male, 2 female) versus 18 (9%) in OH group (18 male). Four out of 15 (27%) in the bilaterally operated cases were not showing bilateral hernia clinically (1 left and 3 right patent processus vaginalis). A total of 4 cases (3 male, 1 female) in the OH group showed contralateral hernia clinically which required surgery within 3 months of first surgery (2%).

Operative time in LH group (unilateral only) was 13-40 min (mean 24 min) versus 10-30 min in the OH group (mean 19 min) which was a statistical significant difference between the two groups (t= 7.4, P0.001). Length of postoperative hospital stay was 1-2 days for both groups.

In LH group there was one case (0.8%) of internal ring hematoma due to injury to inferior epigastric vessel where bleeding stopped spontaneously; there were no intraoperative complications in the open group. There were no postoperative complications in the LH group. There were two cases (1%) of postoperative wound infections in OH group as well as two cases of postoperative residual hydrocele (1%) which resolved spontaneously. Follow up period ranged from 8 months to 2 years. There was one recurrence in the LH group (0.8%) and one case (0.5%) of ascending testis in the OH group.

Discussion

The incidence of inguinal hernias in children is approximately 1-4% with higher rates in premature babies. Hernias are a major source of healthcare utilization in the pediatric population [1, 6].

In recent years, repair of laparoscopic inguinal hernia in children has increased and has become more popular [7, 9]. The advantages of laparoscopic repair include minimal invasive ness, no groin incision, visualization of the contralateral side, minimal risk of cord structures injury, and better cosmetic results [9, 10].

Several techniques have been described for laparoscopic hernia repair that involve the use of extra or intra-corporeal knotting and high ligation with or without dissection of the internal ring [11]. Our technique for laparoscopic repair of inguinal hernia involved closure of the internal ring with purse-string intracorporeal nonabsorbable sutures without resection of the processus vaginalis. Schier F. et al [4] used the same technique in his series of 542 children, while Riquelme et al. [12] resected the procesus vaginalis and used purse-string stitchs if the internal ring size was more than 10 mm.

Mean age for LH group was 54 months versus 32 months for OH group. We used laparoscopic repair for older children initially so we can evaluate the results before applying the technique or popularizing it for younger age groups. Schier F. et al. [4] study age range was 4 days to 14 years (median 1.6 years). Bilateral hernia repair was done in 12.5% of LH group versus 9% in OH group. The incidental finding of patent procesus vaginalis of contralateral side at time of surgery in LH group was 27%, compared to Schier F. et al. [4] findings which was 24% that required closure while Valusek et al [13] showed an incidence of 40% [1]. Two percent of the patients in OH group presented with a metachronous hernia. The duration of surgery in both open and closed is almost equal due to improve of techniques and skills of laparoscopy in pediatric surgery.

Mean operative time in our study was 24 minutes and 19 minutes in LH and OH groups respectively, which is comparable to the lowest operative time published in the literature [4]. Postoperative hospital stay was nearly the same in both groups, as patients above one year with no comorbid conditions were discharged the same day of surgery, other patients were discharged one day after surgery in both groups. There was only one case of intraoperative complications in LH group (0.8%). Riquelme et al [12] showed two intraoperative hematomas (2.2%) which resolved without further need for intervention. In postoperative period there were no complications in LH group. However in OH group 2 cases of wound infection (1%) as well as 2 cases of residual hydrocele (1%) were resolved spontaneously. Shalaby et al. [10] had an incidence of 4 % of postoperative hydrocele in which resolved in the follow up period. Schier F. et al. [4] showed 0.7% hydroceles and 0.2% testicular atrophies.

In the follow up period (8 months - 2 years) there were no recurrences or residual hydrocele in both groups, there was 1% incidence of trapped ascending testis which required orchidopexy in the open group. Shalaby et al. [14] documented 4% recurrence in mean 24 months follow up, in Schier F. et al. [4] study there were 4.1% hernia recurrences. Riquelme et al. [12] showed no recurrence in follow up period (5 months - 4 years), which was explained by complete resection of the procesus vaginalis.

Conclusion

Our preliminary results for laparoscopic inguinal herniotomy in children above one year show comparable results to open technique in the short term follow up. Laparoscopic technique is superior in exploring the contralateral side. We will conduct a prospective study with longer follow up to validate these results further.

 

 

References

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