Is routine reinforcement of the posterior inguinal wall necessary for laparoscopic inguinal hernia repair in children? Comment to: Technical refinement of mini-laparoscopic hernia repair in infants and children. Tsai YC, Da Lin C, Chueh SC (2014) Hernia, DOI 10.1007/s10029-014-1327-4.

Abstract

We studied the paper titled ‘‘Technical refinement of minilaparoscopic hernia repair in infants and children’’ by Tsai et al. [1] with great interest. They rightly consider that the 2–4 % recurrence rate of laparoscopic hernia repair (LHR) performed through ligation of the processus vaginalis (PV) alone is disappointing. One should expect at least the same results as in the open herniotomy procedures (1 % recurrence rate) [1], by applying the same principles to a laparoscopic setting. We fully agree with their strategy to establish a solid musculofascial block by approximation of the transversalis arch to the iliopubic tract at the region of the deep inguinal ring (DIR), to improve the results. Ourselves, we performed a similar technique on 80 patients (113 hernia repairs), aged from 10 days to 15 years (mean 4.5 years) and these children are followed up from 6 months to 5.5 years (mean 2.5 years) and no recurrence has been observed [2]. We continue to operate with this procedure until now. Our interference has to do with the question dealt in the introduction of the paper: why does PV ligation in children produce different results when performed openly and when performed laparoscopically? The authors incriminate the presence of femoral or direct inguinal hernias or inability to recognize a widened DIR, in which cases a simple PV ligation would not suffice. In our opinion, the answer lies in the fact that some manoeuvres performed during simple open herniotomy in children are not duly acknowledged, are performed as rituals, and are considered unworthy to be copied and applied in the LHR. These manoeuvres, when applied in open surgery, have a considerable effect on the abdominal wall anatomy, blocking the abdominal outlets. If these effects are not reproduced during LHR by some other equivalent way, the abdominal wall will retreat. As an audit has confirmed, North American pediatric surgeons practicing open hernia repair perform either an inguinal plasty or narrowing or closure of the DIR in 29 % of boys and 51 % of girls with inguinal hernia (IH) [3]. Furthermore, the twisting of the processus vaginalis stump before its ligation, during the open procedure, causes an approximation of its rim which is in contact with the transversalis fascia, causing the contraction of the circumference of the DIR [4, 5]. This manoeuvre is practiced by 66 % of pediatric surgeons [3]. Tsai et al. reproduce these effects in a much more robust way, by approximation of the transversalis arch to the iliopubic tract and consequently are happy to see no recurrences. In conclusion, it is almost certain that, for the LHR procedures to produce equivalent or better results than the open procedures, in matters of recurrence, a strengthening This letter refers to the publication: Tsai YC, Da Lin C, Chueh SC (2014) Technical refinement of mini-laparoscopic hernia repair in infants and children. Hernia [Epub ahead of print]. doi:10.1007/s10029-014-1327-4.