Response to Comment on "Intraoperative Verbal Communication in Pediatric Single-Incision Laparoscopic Percutaneous Extraperitoneal Closure: A Comprehensive Analysis and Educational Implications".

ABSTRACTIntroductionIn pediatric surgery, declining case volumes and restrictions on working hours have intensified the need for efficient training strategies. The operating room remains a central educational environment, yet the nature of intraoperative teaching is unclear. We examined the educational role of intraoperative verbal communication and identified opportunities for improvement.MethodsWe retrospectively analyzed data of unilateral single‐incision laparoscopic percutaneous extraperitoneal closure procedures performed between December 2024 and June 2025 with complete audio and video recordings. Verbal statements were transcribed verbatim, classified by type and content, and analyzed for overall distribution, phase‐specific frequency, composition of attending‐to‐operating surgeon communication, and intraoperative debriefing occurrence during the wound closure.ResultsNineteen cases were included, yielding 7374 statements. The most common content category was General (39.6%), followed by Instrument handling (19.1%), Anatomy (14.9%), and Operation method (14.8%). The proportion for Instrument handling increased to 27.1% during laparoscopic manipulation; that for Private talk rose to 18.5% during wound closure. Communication from attending to operating surgeons was most frequent in the laparoscopic manipulation phase (median, 3.4; interquartile range, 2.6–4.7, per minute), with higher proportions of Commanding (11.8%) and Advising (14.9%) statements. Intraoperative debriefing on the preceding laparoscopic phase occurred in only two cases (10.5%).ConclusionIntraoperative communication during single‐incision laparoscopic percutaneous extraperitoneal closure demonstrates distinct phase‐specific patterns, with heightened directive teaching during the laparoscopic manipulation phase but infrequent reflective debriefing. These findings suggest that systematically incorporating debriefing into the wound closure phase could foster reflective learning, complement real‐time coaching, and enhance the overall educational impact of intraoperative experiences.

Chronic pain after laparoscopic percutaneous extraperitoneal closure is very rare. Here, we report a case of chronic pain after laparoscopic percutaneous extraperitoneal closure in an adolescent patient with inguinal hernia who underwent open repair. A 15-year-old girl was diagnosed with a left indirect inguinal hernia, and laparoscopic percutaneous extraperitoneal closure was performed. However, 6 months later, after strenuous exercise, she developed localized pain around the hernia site. Her pain was well controlled by internal treatment but failed to completely resolve. The pain type was somatic, Tinel's sign was negative, and there was no recurrence of the inguinal hernia. Because she strongly wished to undergo surgery, the Potts procedure with removal of the ligature and excision of the round ligament was performed. Her pain improved after surgery, and further medical treatment was not required. The Potts procedure may be an effective treatment for chronic pain such as in this case.

Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: clinical outcome of 972 repairs done in 3 pediatric surgical institutions

Single-site laparoscopic percutaneous extraperitoneal closure has been widely used for the repair of paediatric inguinal hernia. In this study, we aimed to introduce the usage of a needle grasper in single-port laparoscopic herniorrhaphy in children. In our study, 447 children with inguinal hernia underwent single-port laparoscopic percutaneous extraperitoneal closure between October 2018 and October 2021 in Shenzhen Children' hospital were retrospectively reviewed. Among 447 patients, there were 396 males and 51 females with a mean age of 2.24 ± 0.36years. A contralateral patent processus vaginalis was present in 165 unilateral hernia patients. All patients underwent laparoscopic percutaneous extraperitoneal closure successfully without converting to open operation. The mean operating time in unilateral and bilateral hernia patients were 10.23 ± 2.25 mine and 14.54 ± 2.81 mine respectively. One patient had subcutaneous emphysema, two male patients had inguinal hernia recurrence and none had complications such as hydrocele and testicular atrophy. Additional 0.3cm port was done in 4 cases. The mean follow-up time was 22.36 ± 4.56months. Single-port laparoscopic percutaneous extraperitoneal closure of paediatric inguinal hernia using a needle grasper is a feasible and safe procedure. It has the advantages of fewer skin surgical incisions, short operating time, low complication and low recurrence rate.

Considerable debate exists regarding the benefits of laparoscopic percutaneous extraperitoneal closure (LPEC) over conventional open repair (OR). We assessed the outcomes and feasibility of LPEC compared to OR for pediatric inguinal hernia (IH). We retrospectively analyzed 570 children who underwent LPEC or OR. Parents decided the operative method after obtaining informed consent. Patient characteristics, operative time, complications and contralateral metachronous IH (CMIH) were compared between the groups. A total of 329 children underwent LPEC and 241 underwent OR. There was no significant difference in the incidence of recurrence or testicular ascent between the LPEC and OR groups (0.3% vs 0.4%, P =0.825, 0.3% vs 0.8%, P =0.391, respectively). No testicular atrophy was recognized in either group. One patient with postoperative chronic inguinal pain was recognized in each group. There was no surgical site infection (SSI) in the OR group; however, the LPEC group more frequently demonstrated umbilical port site (UPS)-related complications, such as incisional hernia, minor deformity, granuloma formation, cellulitis and superficial SSI. Ten (4.1%) developed CMIH in OR; in contrast, no case of CMIH was experienced after LPEC (P < 0.001). In conclusion, both LPEC and OR are feasible in the management of pediatric IH, because of their high success rates and low risk of complications. LPEC could be the superior procedure with respect to the prevention of CMIH. However, to maximize the merits of LPEC over OR, it is important to reduce UPS-related complications in LPEC. A longer follow-up is needed to assess male fertility in patients who receive LPEC.

Laparoscopic percutaneous extraperitoneal closure (LPEC) for pediatric inguinal hernia is a simple technique in which a purse-string suture made of nonabsorbable material is placed extraperitoneally around the hernia orifice by a special suture needle (Lapaherclosure™). Concerns have been raised about the extensive learning curve for both attending surgeons and residents to master this technique. This study assesses the difference in learning curves for the safe performance of LPEC by attending surgeons and residents. A retrospective analysis was performed on the surgical charts of 409 consecutive patients (175 girls, 234 boys) who had undergone LPEC for inguinal hernia repair from December 2005 to December 2011 at Jikei University Hospital. The number of operation needed by attending surgeons and residents to reach the appropriate operation time was analyzed by the Mann-Whitney U test. LPEC was performed by three attending surgeons and four residents who had not previously performed LPEC. The standard operation time for LPEC by attending surgeons who have performed more than 100 LPEC cases safely is 30 min. In our study, the attending surgeons needed a mean of 12 operations (range, 10-16) to reach 30 min for LPEC. Three residents needed a mean of 31 operations (range, 27-33) to reach 30 min for LPEC. The fourth resident could not perform LPEC in 30 min or less. The difference between the number of operations needed by the attending surgeons and the residents to perform LPEC safely was statistically significant (P < 0.05). The overall incidence of contralateral patent processus vaginalis was 47.9 %. Our learning curve analysis showed that whereas attending surgeons needed a mean of 12 operations to perform LPEC repairs safely in 30 min or less, residents needed more than 30 operations to safely perform LPEC repairs without supervision.

Recently, laparoscopic percutaneous extraperitoneal closure (LPEC) for pediatric inguinal hernia has become more popular. The aim of this study was to compare LPEC with open repair (OR) performed in one institution. In total, 1050 patients underwent OR from July 2003 to June 2008, and 1017 patients underwent LPEC from July 2008 to June 2013. The mean follow-up period was 100 months in OR and 40 months in LPEC (p < 0.01). Given the difference in the follow-up periods, the log-rank test was used for the analysis of the long-term results. The mean age at operation in OR and LPEC was 3.72 and 3.75 years, respectively (p = 0.81). The mean body weight was 14.73 and 14.72 kg, respectively (p = 0.98). The male/female ratio was 617/433 and 561/456, respectively (p = 0.10). In the LPEC procedure, the asymptomatic contralateral internal ring was routinely observed, and when a patent processus vaginalis (PPV) was confirmed, prophylactic surgery was performed. The mean operative time for unilateral surgery in OR and LPEC was 28.5 and 21.2 min, respectively (p < 0.01). The mean operative time for bilateral surgery was 52.3 and 25.4 min, respectively (p < 0.01). Recurrence was confirmed in 0.52% in OR and in 0.27% in LPEC (p = 0.53). In the LPEC group, 41.7% of patients with clinically unilateral inguinal hernia were confirmed to have a contralateral PPV and underwent prophylactic LPEC. Contralateral metachronous inguinal hernia (CMIH) was seen in 6.48% in OR and in 0.33% in LPEC (p < 0.01). Two patients showed postoperative testicular atrophy, and two had iatrogenic postoperative cryptorchism after OR, while no postoperative testicular complications were seen after LPEC. Both OR and LPEC obtained satisfactory results from the perspective of recurrence rate and complications. Prophylactic contralateral LPEC is useful for preventing CMIH without prolonging operative time compared with OR. The midterm safety and efficacy of LPEC are proven.

Laparoscopic repairs for children with inguinal hernia have been established with various technical modifications. Laparoscopic percutaneous extraperitoneal closure (LPEC) is one of the most recognized techniques. Although the rate of complications of LPEC is similar to conventional repairs, the major cause of recurrence is still incompletely understood. The purpose of this study is to evaluate detail profile of the cause of recurrence in children treated with LPEC. A systematic literature search was performed using the combinations of the following terms "pediatric inguinal hernia", "LPEC", "complication", and "recurrence" for studies published between 2002 and 2020. The relevant cohorts of recurrence of LPEC in children were systematically searched for clinical outcomes. 35 studies met defined inclusion criteria, reporting a total of 121 patients who had recurrence after LPEC. The mean age at primary operations was 46.7 ± 52.0months. The gender proportions were 63.9% (male) and 36.1% (female). The rate of treatment side was 44.5% (right), 37.0% (left) and 18.5% (bilateral). The hernia sac was closed with absorbable suture materials (5.3%) and non-absorbable (94.7%). The recurrence occurred in 6.9 ± 8.5months postoperatively. Operative findings of reoperation were loosening of the knot of internal rings (61.1%), low ligation of the inguinal canal (16.7%), and skipping (22.2%). This study suggests that male infants have a higher risk of recurrence after LPEC, and the majority of recurrences can occur in a year postoperatively. It is important to confirm carefully that the suture is tight and high without skipping.

This study aimed to compare the safety and efficacy of laparoscopic percutaneous extraperitoneal closure (LPEC) and conventional open repair (OR) for inguinal hernia in infants younger than 6 months. The medical records of 202 patients who had undergone LPEC or OR at an age younger than 6 months between 2010 and 2016 were reviewed. Patient characteristics and surgical outcomes were compared between LPEC and OR. In total, there were 120 LPEC (76 males, 44 females) and 83 OR (76 males, 7 females) cases. There were no differences in median age, median bodyweight, and presence of incarceration between the two groups (LPEC group: 3 months (range, 0-5 months), 5.7 kg (range, 2.3-9.6 kg), and 13.3%; OR group: 3 months (range, 1-5 months), 5.5 kg (range, 2.1-9.0 kg), and 12.0%). LPEC was completed in all cases without any intraoperative complications or open conversions. In the LPEC group, 60.0% of unilateral hernia patients had a contralateral patent processus vaginalis and underwent prophylactic closure. The incidence of metachronous contralateral hernia was significantly lower in the LPEC group than in the OR group (0% vs 10.0%, P < 0.01). Operative time was significantly shorter during LPEC than during OR (P < 0.01) for male patients. The recurrence rate was lower in the LPEC group (0.83%) than in the OR group (2.4%), but the difference was not significant. The present data indicate that LPEC is comparable to OR in terms of safety and efficacy in infants younger than 6 months. Moreover, among the LPEC group, there were fewer incidences of metachronous contralateral hernia, and the procedure had a shorter operative time.

Laparoscopic percutaneous extraperitoneal closure (LPEC) has become routine for repairing pediatric inguinal hernia (IH). Reports on the effective repair of IH in challenging cases, such as extremely low birth weight infants (ELBWI) who become symptomatic soon after birth and have surgery before 1year of age, are rare; and conventional herniotomy (CH) in ELBWI requires extensive experience of neonatal surgery. We compared LPEC with CH for treating ELBWI with IH. Consecutive ELBWI with IH treated by either LPEC (n = 17) or CH (n = 22) before 1year of age between 2012 and 2017 were reviewed. LPEC were performed by consultant pediatric surgeons (CPS; n = 3) with experience of at least 200 cases each. In CH, 11 cases were treated by CPS and 11 by CPS-supervised surgical trainees. There were no intraoperative complications. Operative time and anesthesia time for bilateral IH repairs were both shorter in LPEC. Postoperative sequelae were recurrence (LPEC; n = 1; repaired by redo LPEC 2 months after the initial repair) and intravenous rehydration (CH; n = 1; for persistent post-anesthetic vomiting). Recovery was unremarkable in all cases without additional analgesia. LPEC would appear to be a viable option for treating IH in ELBWI, especially bilateral cases.

Laparoscopic procedures for inguinal hernias and hydroceles in children have become widespread in the past few decades. The purpose of this study was to perform a retrospective analysis of our experience in order to assess the safety and efficacy of laparoscopic percutaneous extraperitoneal closure (LPEC) and to compare the findings with those of conventional open repair (OR). We analyzed the medical records of 488 patients who underwent LPEC or OR for inguinal hernia or hydrocele at our institute between April 2008 and December 2012. The indications for the operation, length of the operation, complications, day surgery, contralateral patent processus vaginalis, and incidence of metachronous contralateral hernia were investigated. The chi-squared test, unpaired t test, and Steel-Dwass test were used to analyze the significance of the data. Among a total of 488 patients, 326 patients underwent LPEC (125 males and 201 females), and 162 underwent OR (140 males and 22 females). There was no significant difference in the incidence of recurrence (three in the LPEC and none in the OR group, P=.55) or in the success rates of day surgery (97.8% in LPEC versus 97.6% in OR). The incidence of metachronous contralateral hernias in the LPEC group was lower than that in the OR group (LPEC 0%; OR 2.2%, P=.03). Seventeen subjects with hydroceles were treated by LPEC without any complications. LPEC is safe and effective for inguinal hernias and hydroceles in children, regardless of age, sex, and incarceration and could reduce the incidence of metachronous contralateral hernias.

Laparoscopic surgery is widely used for pediatric inguinal hernia repair, but evidence from resource-limited settings remains scarce. This study compared outcomes of open herniotomy (OH) and laparoscopic percutaneous extraperitoneal closure (LPEC) in a regional Thai hospital. We conducted a retrospective review of children who underwent OH or LPEC between January 2018 and January 2024. A one-to-one propensity score-matched cohort was created based on age and sex. Outcomes included operative time, anesthetic time, and complications. Univariable and multivariable linear regression identified factors influencing operative and anesthetic time. Among 358 operations, 118 matched pairs (236 patients) were analyzed. Median operative time was longer for unilateral LPEC (30 vs. 25min, p < 0.001) but shorter for bilateral cases (35 vs. 45min, p = 0.027). Anesthetic time was longer in unilateral LPEC (70 vs. 55min, p < 0.001) with no difference for bilateral repairs. Multivariable analysis showed LPEC added 4.3min (95% CI: 0.8-7.9) to operative time after adjusting for confounders. Complication (OH 15.0% vs. LPEC 13.5%) and recurrence rates (1.2% vs. 1.1%) were similar. Metachronous contralateral inguinal hernia (MCIH) occurred only in OH (13.4%), whereas CPPV was detected in 38.6% of unilateral LPEC cases (NNT = 9). LPEC is safe, prevents MCIH, and should be considered a first-line option when available.

BackgroundInguinal hernia is one of the common diseases in infants and children that requires operative treatment. Laparoscopic inguinal hernia repair in children has become an alternative to the open procedure. Laparoscopic percutaneous extraperitoneal closure with peritoneum reinforcement (LPECPR) is a safe and effective approach for pediatric inguinal hernia, and has a lower recurrence. This is a retrospective study to present our experience with children who underwent LPECPR.MethodsA total of 2,018 patients with inguinal hernia who underwent LPECPR in our hospital from July, 2011 to December, 2020 were reviewed. The surgical technique is modified on the basis of laparoscopic percutaneous extraperitoneal closure (LPEC) to close extraperitoneally by circuit suturing twice around the internal inguinal ring.ResultsAll cases were completed LPECPR without conversion. There were no intraoperative complications. A total of 2,018 patients’ laparoscopic procedures were achieved. The mean operative time was 14 and 20 min for unilateral and bilateral operations, respectively. Follow-up to date is 13.4 months (6–36 months), there were no postoperative complications, such as knot reactions, hydrocele formation, testicular atrophy or pain, except 3 recurrences (3/2,018, 0.15%).ConclusionsThis modified LPECPR technique can acquire lower recurrence rate for repair pediatric inguinal hernia. The midterm safety and efficacy of LPECPR are proven and it can be a routine procedure.

Laparoscopic percutaneous extraperitoneal closure compared to open repair for recurrent inguinal hernias in children: A multicenter retrospective study.

We use the laparoscopic percutaneous extraperitoneal closure (LPEC) method as the standard procedure for pediatric inguinal hernia. Despite judging there to be no contralateral patent processus vaginalis (PPV) at the time of the first LPEC, we experienced five cases in which metachronous contralateral inguinal hernia (MCH) developed, so we report the characteristics, including the predictors. For pediatric inguinal hernia, the LPEC method was used in 1277 cases from 2005 to 2019 in our department. Of these, 374 patients underwent unilateral LPEC, and we compared the 5 patients with MCH onset and the 369 without MCH onset. The items to be examined were the gender, age, presence of a low birth weight, initial-onset side, and contralateral internal inguinal ring classification. There was no significant difference in the gender, age, initial-onset side, or contralateral internal inguinal ring classification between the two groups. Low-birth-weight infants were significantly more common among those with MCH than among those without MCH. The only predictor of a contralateral onset after LPEC for pediatric inguinal hernia was a low birth weight. Therefore, for the above-mentioned unilateral LPEC cases, the possibility of a contralateral onset after LPEC due to acquired factors rather than congenital factors should be considered.