Contralateral Inguinal Ring Research Articles

ThP2.14 - Staged laparoscopic traction orchidopexy (SLTO) for impalpable testes

Abstract Aim SLTO enables elongation of the testicular vessels without division by Shehata (JPS 2015). We presented first UK data in 2020 assessing SLTO. It was suggested that a single stage traction procedure may be possible in some patients. We now present follow up data including the single stage traction technique. Methods Data was collected prospectively from a single centre and grouped into 2 time periods: Group A (March 2017 to July 2019), Group B (November 2020 to December 2023). The gubernaculum was divided. If the vascular pedicle was long enough to allow the testis to reach the contralateral inguinal ring the testis was brought down to the scrotum using an 11mm STEP port and secured in a subdartos pouch with 2/0 Ti-cron. If the vascular pedicle was short, 2-stage traction was performed by securing the intra-abdominal testis to the contralateral anterior abdominal wall using a 2/0 Ti-cron stitch. 3-6 months later the testis was brought down to the scrotum as described above. A prospective database was used for data collection and analysis. Outcome measures included presence of a palpable testis in the scrotum at follow-up, ultrasound determined testicular volumes and percentage difference compared to contra-lateral testis where applicable and complications. Follow up was 6 months following the 2nd stage procedure. Results The later cohort (Group B) demonstrated a higher proportion (32%) of single stage procedures compared to Group A (0%). The success rates for both groups were high 95-100%, with a significantly reduced complication rate (9%) seen in Group B compared to Group A (33%) p=0.048.

Comparison of long-term outcomes of laparoscopic percutaneous internal ring suturing and classic open approach for inguinal hernia repair in children.

Inguinal hernia repair is one of the most common surgeries in children. Recently, the use of minimally invasive techniques for inguinal hernia repair has increased in children. Laparoscopic percutaneous internal ring suturing (PIRS) is a technique described for paediatric inguinal hernia repair. The primary objective of this study is to demonstrate the efficacy and reliability of PIRS in paediatric patients through a comparative analysis with an open method. Between January 2017 and June 2023, records of patients who underwent surgery for inguinal hernia were retrospectively reviewed. In total 126 patients were included in the study. They were divided into two groups: 33 patients underwent PIRS (group 1) and 93 patients underwent open repair (group 2). Operation time, cost and complications were compared. The mean age of the 126 patients was 3.23 ± 2.4 years. The mean unilateral operative time was 25.13 ± 5.32min in group 1 and 30.28 ± 4.73min in group 2, and there was a statistically significant difference in operative time (p < 0.001). Two patients in group 1 underwent surgery owing to patent processus vaginalis, whereas three patients in group 2 underwent surgery owing to metachronous hernia. There were no major complications such as bleeding requiring surgical intervention or conversion to an open approach during surgery in group 1. No recurrent hernia was observed in any of the 126 patients. PIRS offers a safe, easy-to-learn method with low complication rates. PIRS has a distinct advantage over open surgical repair because of its capacity to evaluate the contralateral inguinal ring.

Laparoscopic intra-abdominal patent processus vaginalis ligation in pediatric urology practice

Inguinal hernias and communicating hydroceles from a patent processus vaginalis (PPV) are common problems in children. This study provides a detailed description of the laparoscopic intra-abdominal patent processus vaginalis ligation (LIPPL) procedure along with its results in pediatric urology patients. Prospectively collected data were captured from children (<18 years) who underwent LIPPL from 2012 to 2014. Demographics as well as postoperative characteristics were reviewed and descriptively analyzed. LIPPL is performed using a 5-mm camera through the umbilicus. A loop of polypropylene suture is passed through a spinal needle percutaneously on one side of the internal ring. The needle is reinserted on the opposite side and the tail of the suture is fed through the original loop such that a purse-string is created around the peritoneum of the internal ring above the spermatic vessels and the vas; the suture is tied extracorporeally. 142 patients (3 female) were evaluated with 197 PPV sites repaired using LIPPL at median 24 (1-216) months of age. Median operating time was 35 (20-91) and 43 (27-85) minutes for unilateral and bilateral repairs, respectively. There were no intraoperative complications. During the 14 (1-34) months from surgery, there were no hernia recurrences, one surgical site infection, seven patients with residual small non-communicating hydroceles, and one patient who developed a suture granuloma. LIPPL is a safe and effective technique with minimal rate of hernia recurrence and few complications. LIPPL allows for easy repair of all sizes of PPV, with patients receiving the benefits of minimally invasive surgery including the ability to evaluate the contralateral inguinal ring.

Laparoscopic treatment of nonpalpable testicle. Factors predictive for diminished size

PurposeThe purposes of this study were to demonstrate the usefulness of laparoscopy in intraabdominal testicle (IAT) and to determine factors associated with diminished size during the final outcome after laparoscopic orchidopexy. MethodsThis is a retrospective analysis of consecutive patients from 1999 to 2013 with a minimum follow-up of 1year. Patient and testicular factors were related to diminished size. ResultsSixty one patients, and 92 testicles were included. Median age at operation was 42months. Initially we found 66 normal sized testes (71.7%), 22 hypotrophic (23.9%) and four atrophic (4.3%). Eighty seven testes were brought down laparoscopically, 50 in one surgical stage and 37 in two stages. Mean follow-up was 40.2months and the final outcome was success: 73.5% and diminished size: 26.5%. Variables associated with diminished size were hypotrophy during initial evaluation, short spermatic vessels, section of spermatic vessels, two-stage surgery and tension to reach contralateral inguinal ring. Multivariate analysis showed that initial hypotrophy (odds ratio [OR] 4.96, confidence interval 95% [CI] 1.36–18.10) and tension to reach contralateral ring (OR 4.11, 95% CI 1.18–14.34) were associated with diminished size. ConclusionsLaparoscopy is useful in treating IAT. Initial size and tension to reach contralateral ring are factors associated with diminished size.

Long-term Outcome of Laparoscopic Hernia Sac Transection and Intracorporeal Ligation in Children: A Single Center Cohort Study

Purpose: Laparoscopic hernia repair in children is still controversial. The aim of this study was to report our long-term results of the laparoscopic hernia technique, which is based on the same surgical principles as conventional open herniotomy. Methods: Five hundred fourteen pediatric patients with inguinal hernia were included in this study under informed consent. All patients underwent a laparoscopic technique of sac transection and intracorporeal ligation. The asymptomatic contralateral inguinal ring was routinely explored and repaired if a patient had patent processus vaginalis on the contralateral side. Patients were prospectively followed for 5 years. Those who were lost to follow-up were excluded from the study. Perioperative complications and recurrences were evaluated. Results: The mean follow-up period was 29 months. Mean operation time was 27.5 minutes. Forty one percent of the patients had contralateral patent processus vaginalis. Only one hernia recurred (0.19%). We had one case of contralateral metachronous hernia (0.21%) during follow-up period. Conclusion: The long-term follow-up results of our study revealed that laparoscopic hernia sac transection and ligation can be a safe and effective alternative for conventional herniorraphy.

Evaluation of the contralateral inguinal ring in clinically unilateral inguinal hernia: a systematic review and meta-analysis

The management of the contralateral inguinal canal in children with clinical unilateral inguinal hernia is controversial. Our objective was to systematically review the literature regarding management of the contralateral inguinal canal. We searched MEDLINE, EMBASE, and Cochrane databases (1940-2011) using 'hernia' and 'inguinal' and either 'pediatric,' 'infant,' or 'child,' to identify studies of pediatric (age ≤21 years) patients with inguinal hernia. Among clinical unilateral hernia patients, we assessed the number of cases with contralateral patent processus (CPP) and incidence of subsequent clinical metachronous contralateral hernia (MCH). We evaluated three strategies for contralateral management: expectant management, laparoscopic evaluation or pre-operative ultrasound. Pooled estimates of MCH or CPP were generated with random effects by study when heterogeneity was found (I(2) > 50 %, or Cochrane's Q p ≥ 0.10). We identified 2,477 non-duplicated studies, 129 of which met our inclusion criteria and had sufficient information for quantitative analysis. The pooled incidence of MCH after open unilateral repair was 7.3 % (95 % CI 6.5-8.1 %). Laparoscopic examination identified CPP in 30 % (95 % CI 26-34 %). Lower age was associated with higher incidence of CPP (p < 0.01). The incidence of MCH after a negative laparoscopic evaluation was 0.9 % (95 % CI 0.5-1.3 %). Significant heterogeneity was found in studies and pooled estimates should be interpreted with caution. The literature suggests that laparoscopically identified CPP is a poor indicator of future contralateral hernia. Almost a third of patients will have a CPP, while less than one in 10 will develop MCH when managed expectantly. Performing contralateral hernia repair in patients with CPP results in overtreatment in roughly 2 out of 3 patients.

Is There an Increased Risk of Complications with Laparoscopy Looking for a Contralateral Patent Processus Vaginalis?

In young children with a unilateral congenital inguinal hernia, the relatively high incidence of an occult contralateral patent processus vaginalis (CPPV) has led to the practice of laparoscopic contralateral exploration. The effect on postoperative complications such as surgical site infection from performing the laparoscopy has not been previously reported. A retrospective review was conducted on all patients who underwent a unilateral inguinal hernia repair from January 1, 2000 to March 1, 2010. We compared those children who underwent laparoscopic evaluation of the contralateral inguinal ring with those who did not. Patient demographics and operative data outcomes were evaluated. Student's t test was used to compare continuous variables, and the chi-squared test with Yates's correction was used for discrete variables. There were 1164 patients who underwent a unilateral inguinal hernia repair during the 10-year study period, and laparoscopy was used in 1010 patients. There were no intraoperative complications from the laparoscopy. In the group who underwent laparoscopy, the mean age was 4.0±3.6 years old, and 88% were male. At laparoscopic exploration, 315 (31%) patients were found to have a CPPV. There were 10 patients (1.0%) who developed a surgical site infection. Infection developed in the side used for laparoscopic exploration in 9 patients and in the contralateral side in 1 patient. All patients with surgical site infections were treated initially with oral antibiotics. Abscesses developed in 2 patients, requiring incision and drainage. No patient required hospital admission or reoperation. In the 154 patients who did not undergo laparoscopy, mean age was 4.3±4.4 years (P=.35), and 85.8% were male (P=.54). There was one wound infection identified in this control group (0.6%) (P=1.00). There was no difference in rate of recurrence (control group, 0%; exploration group, 0.6%; P=.72). There is minimal risk of infection or recurrence following unilateral inguinal hernia repair, and this risk is not increased with the use of contralateral exploration using laparoscopy.

Inguinal hernia: what we have learned from laparoscopic evaluation of the contralateral side

The evaluation for and management of a contralateral patent processus vaginalis in children presenting with a unilateral inguinal hernia has been debated for over 60 years. The emergence of transinguinal laparoscopy as an evaluative tool has changed the landscape of the debate, offering a safe and minimally invasive option. The review will highlight some of the significant recent contributions to this debate. Recent studies have confirmed the safety of transinguinal laparoscopy, and demonstrated a high level of sensitivity and specificity for it in the evaluation of the contralateral inguinal ring. In comparison, the practice of physical examination under anesthesia for evaluation of the contralateral inguinal region has proven to be ineffective. Further, age and gender differences in the incidence of contralateral patent processus vaginalis have recently been challenged. These data call into question the practices of routine or selective open inguinal exploration and present laparoscopy as the most effective means of evaluation. Transinguinal laparoscopy offers a safe and effective means of evaluating the contralateral inguinal ring during ipsilateral hernia repair. The relatively high incidences of both contralateral patent processus vaginalis and contralateral metachronous hernia development in children justify the use of routine laparoscopic evaluation.

Incidental Inguinal Hernias on Laparoscopy

Laparoscopic examination of the contralateral inguinal ring has been advocated to exclude contralateral hernia in young children. We used the size of the open internal ring and the depth of the patent processus vaginalis as a parameter to decide whether laparoscopic herniotomy was indicated. Records of all laparoscopic procedures in children performed in a large tertiary care hospital over a 2.5-year period were retrospectively analysed. Laparoscopy in 346 children revealed the presence of an incidental asymptomatic patent processus vaginalis in 47 cases. Of these, 38 were present as a contralateral hernia among 171 laparoscopies for inguinal hernias. The presence of an incidentally detected, asymptomatic but significant-sized open internal ring is not uncommon. The authors recommend that a 1-cm diameter and a 2-cm depth of open internal ring be taken as a significant indication for herniotomy. The authors also emphasize that a reported incidence of contralateral patent processus vaginalis of up to 56.2% justifies the procedure of laparoscopic herniotomy in all children.

Is the use of laparoscopy to determine presence of contralateral patent processus vaginalis justified in children greater than 2 years of age?

Purpose Contralateral inguinal hernia exploration in cases of unilateral inguinal hernia remains a controversial topic. The authors have been using the in-line laparoscopic technique of contralateral evaluation for unilateral inguinal hernia in children less than 2 years of age. Because of the case of the procedure and lack of morbidity, we decided to expand the use of this procedure up to age 8 years in January 2000. The purpose of this study is to evaluate if the incidence of contralateral hernia in children greater than 2 years justifies the procedure. Methods This is a retrospective study of all children who underwent contralateral exploration for unilateral inguinal exploration over a 20-month period. The procedure was offered routinely to all patients up to age 8 years. During the repair, the contralateral inguinal ring was examined laparoscopically using the in-line technique for the presence of a contralateral hernia. The incidence of contralateral hernia was determined, and the results were stratified by age. Patients who underwent unilateral inguinal hernia repair without laparoscopic contralateral exploration or bilateral inguinal hernia repair without laparoscopic contralateral explorations were excluded from the study. Results A total of 284 laparoscopic explorations were performed. Positive explorations were seen in 65 of 171 (38%) of children less than 2 years of age, 19 of 101 (20%) of children 2 to 8 years of age, and 1 of 12 children greater than 8 years of age (8%). There were no operative complications. Conclusions Laparoscopic contralateral exploration is safe and effective. Because of the low morbidity, the risk to benefit ratio warrants its use in children up to 8 years of age. This sample size is too small to make any meaningful statement in children older than 8 years.

Laparoscopically Assisted Correction Of Transverse Testicular Ectopia

Transverse testicular ectopia or crossed testicular ectopia is a well described congenital anomaly in which the 2 testes descend through a single inguinal canal. The usual clinical presentation is an impalpable testis on 1 side and a normally descended testis with symptomatic inguinal hernia on the contralateral side. The patient often undergoes unsuccessful inguinal exploration and the ectopic testis is usually discovered operatively during herniotomy. CASE REPORT A 2-year-old boy was referred in May 1998 for evaluation of an impalpable right testis after negative inguinal exploration was performed elsewhere. Physical examination demonstrated a right inguinal incision with a nonpalpable testis. The left hemiscrotum was remarkable for a communicating hydrocele. Left communicating hydrocele repair was planned with diagnostic laparoscopy through the patent processus vaginalis. When the tunica vaginalis was opened, a tubular structure was noted running from the testis more proximal into the peritoneal cavity. Careful traction on this structure revealed a contralateral intra-abdominal testis, which was present in crossed, fused fashion (see figure). With this entity identified laparoscopic entry was achieved via a 5 mm. umbilical port. The gubernaculum connecting the 2 testes was divided. A right inguinal incision was made and a Kelly clamp was passed through it under laparoscopic guidance. The crossed testis was then grasped at the site of the gubernaculum and passed to the contralateral inguinal ring. Standard right orchiopexy was performed using a subdartos pouch. Notably generous cord length on this side obviated the need for a Fowler-Stephens procedure. Long-term followup confirmed 2 healthy testes in their respective orthotopic locations. DISCUSSION

Groin Laparoscopy in Pediatric Patients with Clinical Unilateral Inguinal Hernia: An Improved Technique Using the Bronchoscope

Contralateral inguinal exploration in children with unilateral inguinal hernia is still controversial. The authors report the transinguinal laparoscopic evaluation of the opposite site with the rigid bronchoscope. In 51 children (42 boys, 9 girls) with clinical unilateral inguinal hernia, under general anesthesia, the hernia sac was opened, a port was placed, and pneumoperitoneum was induced. A 30° angle rigid bronchoscope was inserted in the port, and the contralateral groin was explored laparoscopically. In difficult cases, a catheter was introduced through the working channel of the bronchoscope to detect a hernia sac. Contralateral inguinal hernia was present in 10 children (19.6%). In 3 of these 10 patients (30%), the hernia sac could not be established by simple inspection but was demonstrated by probing. There were no false positive or false negative findings. Follow-up varied from 1 to 24 months. There were no recurrences of hernia on either side. No complications were noted. Transinguinal laparoscopy with the rigid bronchoscope, in children with clinical unilateral inguinal hernia, provides a fast, safe, accurate and precise method for evaluation of the contralateral groin. The working channel of the bronchoscope allows probing of the contralateral inguinal ring and improves the outcome of the diagnostic laparoscopy. The risks of the standard laparoscopy, using a puncture wound, are avoided. The routine contralateral inguinal exploration and its complications are prevented.

The value of intraoperative laparoscopic examination of the contralateral inguinal ring during hernia repair in children.

Approximately 40% of children with a clinical unilateral inguinal hernia display a patent processus vaginalis on the contralateral side; half of these children subsequently develop an inguinal hernia. The management of this problem is still controversial. Different strategies to identify patients who profit from an open contralateral exploration have been applied (diagnostic pneumoperitoneum, herniography, ultrasound). The purpose of this study was to evaluate the usefulness of intraoperative laparoscopy in a no-puncture technique through the opened hernia sack. In 75 children (age 6 months to 7 years) with clinical unilateral hernia laparoscopy (5-mm Laparoscope, 30 degrees and 70 degrees ), in cases of wide-open contralateral internal inguinal ring (Type III) an open surgical exploration was performed. Twelve patients (17%) fulfilled the laparoscopic criteria of a Type III ring. The diagnose was confirmed during open contralateral exploration. Seven children (8%) showed a patent but small processus vaginalis with a shallow internal ring. These patients were treated conservatively. In the follow-up period (median 6 months) one subsequent hernia developed. There was no technical failure, and no associated complications were seen. The median time for laparoscopy was 6 minutes. Intraoperative laparoscopy during unilateral hernia repair allows the identification of patients who profit from bilateral open surgery during the same operation with little additional operating time, and so far with no resulting complications. Application of this method may avoid a second hospitalization and operation as well as unnecessary routine bilateral open exploration. As an additional source of information through excellent visualization of the abdominal cavity, this method proved helpful to examine the incarcerated bowel after repositioning.

Cost-effective endoscopic examination of the contralateral inguinal ring

Laparoscopic examination of the contralateral inguinal ring has recently been advocated to exclude contralateral hernia in young children. We report a modification using nondisposable cystoscopic equipment, which is quick and reliable. Either an 8 or 10 F soft straight catheter or a cystoscope sheath is passed through the open hernia sac. Air is insufflated into the abdomen with a syringe. Once the pneumoperitoneum is completed, a 4-mm cystoscope lens (110 degrees) is used to inspect the contralateral ring. Twenty-four children between the ages of 6 weeks and 4 years (median, 6 months) underwent exploration for presumed unilateral inguinal hernia and laparoscopic examination of the contralateral inguinal ring. Thirteen patients (54%) had an open processus vaginalis and underwent contralateral inguinal herniorrhaphy. No false-positive or false-negative results were found, and there were no complications associated with the procedure. This method of laparoscopic examination of the contralateral inguinal ring using nondisposable cystoscopic equipment is rapid, safe, reliable, and cost effective in evaluating a contralateral patent processus vaginalis. Laparoscopic examination spares the need for formal surgical exploration in patients with a closed processus vaginalis.