Although camera navigation is integral to pediatric endoscopic surgery, no validated framework exists for assessing laparoscopist performance. This study evaluated the validity of a modified Objective Structured Assessment of Camera Navigation Skills (OSA-CNS) and investigated how laparoscopist performance influenced procedural safety. This retrospective study evaluated unilateral single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) procedures performed in males at our institution between January and December 2022. Laparoscopist performance was assessed using a modified OSA-CNS. Two blinded raters independently scored surgical videos to evaluate inter-rater reliability and internal consistency. Technical errors and events were obtained from previous studies using the Generic Error Rating Tool. Modified OSA-CNS scores were compared using the Kruskal-Wallis test. The associations of laparoscopist performance with errors, events, and procedure time were analyzed using surgeon-clustered linear regression. Briefly, 25 unilateral procedures with 185 errors and 40 events were included. The median procedure time was 23.3 (20.3-29.4) min. The modified OSA-CNS demonstrated excellent inter-rater reliability (intraclass correlation coefficient = 0.96) and internal consistency (Cronbach's α = 0.88-0.91). It distinguished performance across laparoscopists with differing experiences (P = .0020). Higher laparoscopist scores were associated with fewer errors (β = -0.19, 95% CI: -0.34 to -0.04; P = .025) but not with event counts or procedure time. The modified OSA-CNS is reliable and valid for evaluating laparoscopist performance in pediatric SILPEC. Its ability to reflect skill differences and its association with error frequency underscore its value in surgical education and intraoperative safety improvement.

To explore the clinical phenotypes and genetic etiology of a child with MRXS34 syndrome due to a variant of NONO gene. A child patient who presented at Shanxi Provincial Maternity and Child Care Hospital on September 28, 2020 was selected as study subject. Clinical data of the child were retrospectively collected. Peripheral blood samples were collected from the child and his parents. Following extraction of genomic DNA, whole exome sequencing (WES) was carried out. Candidate variant was verified by Sanger sequencing of the family members. Pathogenicity of the variant was assessed based on guidelines from the American College of Medical Genetics and Genomics (ACMG). Quantitative reverse transcription polymerase chain reaction (RT-qPCR) was used to detect the effect of the NONO gene variant on messenger RNA (mRNA) expression level in the proband, and complementary DNA (cDNA) sequencing was performed to validate the splicing patterns of the NONO gene variant in the proband. Using the keywords "NONO gene" "MRXS34" "developmental delay" "intellectual disability" and "congenital heart disease", a literature search was conducted in databases including the China National Knowledge Infrastructure(CNKI), Wanfang Data and PubMed databases to identify studies on the clinical and genotypic characteristics of children with MRXS34 caused by NONO gene variants. The search period was set from the inception of the databases to April 2025, and a comprehensive analysis of the findings from the identified studies was performed. This study was approved by the Medical Ethics Committee of the hospital (Ethics No.: IRB-KYHZ-2019-006). The proband, a 3-year-old male, exhibited global developmental delay, intellectual disability, facial dysmorphism, macrocephaly, corpus callosum dysgenesis, cavum septum pellucidum, atrial septal defect, tricuspid valve insufficiency with regurgitation, cryptorchidism, inguinal hernia, and anal cutaneous fistula. The results of WES and Sanger sequencing validation showed that the proband carried a heterozygous variant of the NONO gene c.577_581del (p.Val193fs), while both parents were wild-type, indicating that this variant was a de novo variant. According to the ACMG guidelines, this variant was classified as pathogenic (PVS1+PS2_Moderate+PM2_Supporting). RT-qPCR results showed that the relative mRNA expression level of the NONO gene in the proband was significantly lower than that in the control group of normal children, and cDNA sequencing results verified that the frameshift variant due to base deletion led to nonsense-mediated mRNA decay (NMD), causing premature termination of transcription without exon skipping at the splice site. Using the literature search strategy established in this study, a total of 15 studies on the clinical and genotypic characteristics of children with MRXS34 caused by NONO gene variants were identified, involving a total of 32 patients. Together with the proband of this study, a total of 33 patients were included in the comprehensive analysis. The results revealed a total of 23 types of variants involving the NONO gene. The main clinical manifestations of MRXS34 included developmental delay/intellectual disability (23/24, 95.8%), cardiovascular abnormalities (23/30, 76.7%), craniofacial/somatic malformations (21/24, 87.5%), and corpus callosum dysgenesis (16/21, 76.2%). The NONO gene variant probably underlay the pathogenesis of MRXS34 in this proband. The findings of this study has expanded of the variant and clinical spectra associated with the NONO gene.

Most pediatric inguinal hernias (PIH) result from congenital patency of the processus vaginalis; however, a subset arises from acquired mechanisms involving posterior wall weakness. Representative examples include direct hernias and metachronous contralateral inguinal hernias (MCIH) that develop following negative laparoscopic exploration. In such cases, high ligation alone may be insufficient. This study aimed to evaluate the outcomes of laparoscopic iliopubic tract repair (IPTR) in acquired PIHs, focusing on recurrence, surgical outcomes, and safety. From January 2013 to December 2022, 12,792 pediatric patients younger than 10 years underwent laparoscopic inguinal hernia repair. Among them, 21 patients diagnosed with acquired PIHs were treated with laparoscopic IPTR. The repair involved suturing the iliopubic tract to the transversalis fascia using nonabsorbable suture to reinforce the posterior wall. We evaluated surgical outcomes, including recurrence and safety. Of the 21 patients, 10 had direct hernias and 11 had indirect hernias of MCIH that were initially negative on laparoscopic evaluation but later developed into clinical PIHs. Compared with indirect PIH, direct PIH occurred in patients who were significantly older and heavier (P = .017 and P = .020, respectively). The omentum was the sole herniated organ in direct cases (P < .001). All surgeries were completed laparoscopically without conversion, and no intraoperative or postoperative complications occurred. At a median follow-up of 78 months, no recurrences were observed. Laparoscopic IPTR is a safe and effective surgical approach for acquired PIHs. It provides reliable posterior wall reinforcement and may reduce the risk of recurrence.

Age-stratified outcomes after laparoscopic inguinal hernia repair in children: A large single-center cohort study.

ObjectiveThis study compared the efficacy of ilioinguinal/iliohypogastric, transversus abdominis plane, and quadratus lumborum blocks as adjuncts to spinal anesthesia for postoperative pain management in unilateral inguinal hernia repair.MethodsThis study was a prospective, randomized, controlled, single-blind study. Eighty patients were randomized into four groups: (a) ilioinguinal/iliohypogastric block group; (b) transversus abdominis plane block group; (c) quadratus lumborum block; and (d) control group. Postoperative pain was assessed using the visual analog scale at rest and during movement over 24 h. Total tramadol consumption via patient-controlled analgesia, supplemental paracetamol use, and opioid-related adverse effects were recorded.ResultsNo statistically significant differences were found in visual analog scale scores among the groups at any time point (p > 0.05). Opioid consumption ranged from 60 to 300 mg, with a mean value of 226.79 ± 49.94 mg. There was no statistically significant difference in opioid use among the groups (p = 0.930; p > 0.05). The requirement for additional analgesics did not differ significantly among the groups (p = 0.389; p > 0.05). The overall incidence of adverse effects (postoperative nausea and vomiting, and respiratory depression) was 11.2% (n = 9). No statistically significant differences were observed in the rate of adverse effects between the groups (p = 0.069; p > 0.05).ConclusionNo statistically significant differences were observed in pain scores, opioid consumption, or adverse effects between the three block groups and the control group. There was a nonsignificant trend toward lower visual analog scale scores in the ilioinguinal/iliohypogastric group compared with the transversus abdominis plane and quadratus lumborum groups during the postoperative period. Although the total number of patients requiring additional analgesics was lower in all three block groups compared with the control group, these findings were not statistically significant.Clinical Trial NumberThis trial was retrospectively registered at clinicaltrials.gov with trial number NCT06997536.

Rethinking the Concept of "Acquired" Pediatric Inguinal Hernias.

Inguinal hernia repair is one of the most common surgical procedures worldwide and is frequently performed as day-case surgery. Postoperative pain may delay recovery and occasionally necessitate unplanned hospital admission. Regional anesthesia techniques, including transversus abdominis plane (TAP) and rectus sheath (RS) blocks, have shown promise in improving analgesia. However, their combined efficacy in open inguinal hernia repair has not been established in randomized trials. The PRO-RSTAP trial is a prospective, double-blind, four-arm randomized controlled trial conducted at three hospitals in Finland. The study evaluates the individual and combined effects of TAP and RS blocks in adults undergoing elective open inguinal hernia repair. Two hundred patients are randomized equally into four groups: (1) placebo TAP + placebo RS, (2) active TAP + placebo RS, (3) active RS + placebo TAP, and (4) active TAP + active RS. All patients receive standardized sedation and multimodal analgesia, including paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and rescue opioids. The primary outcome is cumulative perioperative opioid consumption from block administration until hospital discharge, expressed as intravenous morphine equivalents. Secondary outcomes include pain scores, conversion to general anesthesia, postoperative nausea and vomiting, time to discharge, and unplanned admissions or emergency visits within 7 days. The planned sample size provides 80% power to detect a clinically meaningful reduction in opioid use (two-sided α = 0.05). Analyses follow the intention-to-treat principle. The first participant was enrolled in September 2025, and the trial is ongoing. No interim efficacy analysis is planned. Safety is monitored continuously throughout the study. This randomized controlled trial is designed to determine whether combining TAP and RS blocks improves postoperative analgesia and recovery after open inguinal hernia repair. The results will contribute to evidence-based optimization of regional anesthesia strategies in ambulatory surgery. EU Clinical Trials Information System (CTIS): 2024-513406-59-00; ClinicalTrials.gov identifier: NCT07423910.

Robotic-assisted transabdominal preperitoneal repair (rTAPP) is increasingly used for inguinal hernia. However, evidence on its implementation in district hospitals and its integration into resident training programs remains limited. The aim of this study was to assess a real-world implementation of rTAPP in a public district hospital. Patients with inguinal hernia who underwent rTAPP between May 2024 and May 2025 were included. Perioperative outcomes, quality of life (QoL), and recurrence within the first 6 months were assessed. Implementation was analyzed across three consecutive phases to evaluate changes in operative performance and trainee involvement. QoL was measured using the 5-level EQ-5D version (EQ-5D-5L) in a subset of patients with available pre- and postoperative data. A total of 120 patients underwent rTAPP. There were no conversions to laparoscopic or open surgery. Postoperative complications were observed in 8 (6.7%) patients and were limited to Accordion grade I-II events. The median length of postoperative stay was 20 h. One patient (0.8%) experienced hernia recurrence within 6 months. In contrast with phase 1, resident surgeons performed rTAPP in phases 2 (15%) and 3 (12.5%). Mean operative time decreased from 86 min in phase 1 to 74 and 77 min in phases 2 and 3, respectively (p = 0.041) without a significant difference in postoperative complications. Paired EQ-5D-5L data demonstrated significant postoperative improvement in pain/discomfort, daily activities, and overall health score. Robotic-assisted inguinal hernia repair can be safely implemented in a district hospital setting with favorable short-term outcomes. Structured introduction of rTAPP allowed rapid involvement of surgeons without compromising perioperative safety or efficiency.

This study aimed to assess the degree of adherence to key recommendations of the 2023 HerniaSurge International Guidelines for Groin Hernia Management among surgeons performing adult groin hernia repair at a high-volume tertiary government training hospital in the Philippines. International guidelines for groin hernia management provide evidence-based recommendations to standardize the care of groin hernia cases. Despite dissemination, adherence varies across institutions. Evaluating real-world compliance is essential to identify gaps in implementation. A retrospective audit of adult patients who underwent groin hernia repair at the Philippine General Hospital over one year was performed. The primary outcome was guideline adherence rate which was defined as the proportion of cases fulfilling predefined, audit-appropriate operational definitions based solely on ten selected guideline recommendations assessable through routine institutional documentation. A total of 355 patients underwent groin hernia repair during the study period, accounting for 373 hernia units after separating bilateral cases. Use of clinical examination alone for diagnosis of primary inguinal hernias was documented in 203 cases (60.4%), while EHS classification was recorded in 251 cases (70.7%). Appropriate anesthesia was administered in 84.5% of patients, while antibiotic prophylaxis was given in 93.0%. All patients (100%) received recommended postoperative oral analgesics. In contrast, documentation-dependent technical steps such as nerve identification and intraoperative anesthesia infiltration were not recorded in any case, resulting in 0% documented compliance by audit criteria. Among female patients (n = 4), round ligament preservation was documented in one case (25.0%). Compliance patterns varied across training levels and surgical divisions, with higher adherence observed in mesh utilization and prophylaxis than in technical documentation elements. Adherence to guidelines was high for broadly established practices such as mesh-based repair, antibiotic prophylaxis, and post-operative analgesia, but inconsistent for documentation-sensitive technical recommendations. Findings for intraoperative parameters with 0% documented compliance should be interpreted with caution, as these most likely reflect documentation gaps rather than confirmed non-performance. Gaps in adherence may reflect documentation practices as much as technical deviations. This establishes a baseline for institutional quality improvement and future outcome-linked evaluations.

Abstract Background Pierpont syndrome is a rare autosomal dominant disorder caused by pathogenic variants in TBL1XR1 gene, characterized by distinctive craniofacial features, plantar lipomatosis, and neurodevelopmental disorders. Urological malformations were reported, but signifcant kidney function impairment has never been described in previous cases. Case presentation We report an 8-year-old girl with bilateral dysplastic kidneys identified in neonatal period and progression to kidney failure, requiring peritoneal dialysis from age four. Subsequent genetic evaluation confirmed a diagnosis of Pierpont Syndrome. Her course was complicated by recurrent inguinal hernia, peritoneal dialysate leakage, and respiratory compromise related to central and obstructive apnoea. She has been enlisted for kidney transplantation. Conclusion Although causality cannot be established, the concurrence of bilateral dysplastic kidneys and kidney failure in this rare genetic disorder raises important clinical questions. The case also highlights the importance of mutlidisciplinary care in dialysis and transplant planning. Further studies are required to clarify the potential role of TBL1XR1 gene in kidney development and long-term outcomes in Pierpont syndrome.

Laparoscopic assisted percutaneous extraperitoneal closure (LPEC) is widely used in Japan for pediatric inguinal hernia repair and associated with a low recurrence rate. This study aimed to investigate recurrent cases to determine possible causes. This study retrospectively reviewed patients who underwent reoperation for ipsilateral recurrence after the initial LPEC performed at our institution between 2009 and 2024. Recurrence was confirmed through 2025. Medical records and operative videos were analyzed to evaluate patient characteristics, interval to recurrence, operative findings, recurrence patterns, and reoperative procedures. Recurrence rates were also compared based on the suture material. In 1,894 patients, 11 recurrences (0.58%) occurred. No significant differences in age, sex, or side were observed. The median interval to recurrence was 32 months. The video review identified one technical error involving needle deviation into the muscle layer. Two cases were de novo-type recurrences. In nine cases, a central pinhole in the ligation ring suggested ligature loosening. Recurrence rates were lower with polyester sutures than with silk (0.16% vs. 0.79%), though not statistically significant (p = 0.28). LPEC demonstrated a low recurrence rate. Most recurrences were associated with inadequate ligation, and recurrence rates tended to be lower with polyester sutures.

Racial Disparities in Emergent Versus Elective Inguinal Hernia Repair.

In this case series, we describe our approach to the urologic management of ureteral hernias. This is a single‐institution, multi‐surgeon cohort of patients who presented with an abdominal hernia involving a ureter between 2018 and 2025. Among eight patients, seven male patients (87%) had an inguinal hernia involving the ureter. Six patients underwent urologic intervention at the time of inguinal hernia repair, most commonly preoperative ureteral stent placement (40%). Three patients (50%) experienced inguinal ureteral hernia recurrence, of whom two underwent ureteral reimplantation. Based on our experience, the majority of inguinal ureteral hernias can be managed with a preoperative ureteral stent at the time of hernia repair, although more complex ureteral reconstruction may be required in the setting of recurrence.

Asymptomatic contralateral patent processus vaginalis (CPPV) is commonly detected during the laparoscopic repair of inguinal hernias in children and is a risk factor for metachronous contralateral inguinal hernias (MCIHs). However, predicting CPPV preoperatively is challenging, and evidence on its clinical predictors is limited, particularly regarding sex-specific differences. We aimed to identify preoperative predictors of CPPV and to evaluate sex-specific risk factors. This retrospective observational study was conducted at a single tertiary-care university hospital and included children (aged < 16years) who underwent single-incision laparoscopic percutaneous extraperitoneal closure for a clinically unilateral inguinal hernia or hydrocele between 2013 and 2024. Those who underwent surgery for a recurrent inguinal hernia, MCIH, or bilateral presentation were excluded. The preoperative clinical characteristics were analyzed. Missing data were addressed using multiple imputation before conducting multivariable logistic regression analyses in the overall and sex-stratified cohorts to determine the independent predictors of CPPV. Overall, 1031 children (502 males, 529 females) were included. CPPV was identified in 511 (49.6%) patients. In the multivariable analysis of the overall cohort, left-sided presentation and history of incarceration were independently associated with CPPV, whereas sex was not. In sex-stratified analyses, hydrocele was independently associated with CPPV in males (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.06-2.45; P = 0.03). In females, left-sided presentation (OR, 2.80; 95% CI, 1.94-4.03; P < 0.001), incarceration history (OR, 5.19; 95% CI, 1.39-19.30; P = 0.014), and older age (OR, 1.01; 95% CI, 1.00-1.01; P = 0.046) were associated with CPPV. Preoperative predictors of CPPV showed sex-specific patterns. Sex was not an independent predictor; however, hydrocele was associated with CPPV in males, whereas, in females, left-sided presentation and incarceration history showed strong independent associations with CPPV. These findings may inform preoperative counseling, operative approach selection, and meticulous contralateral laparoscopic exploration, potentially reducing the risk of subsequent MCIH.

Robot-assisted radical prostatectomy (RARP) has become the standard surgical treatment for prostate cancer. The Retzius-sparing approach (RS-RARP) offers improved functional outcomes; however, detailed data on non-functional perioperative and postoperative complications remain limited. This study aimed to evaluate the incidence, spectrum, and management of complications following RS-RARP in a large series and to assess the impact of progressive technical modifications. We performed a retrospective analysis of a prospectively maintained database of 1016 consecutive patients who underwent RS-RARP between 2016 and 2025. Complications were recorded intraoperatively and postoperatively and graded using the Clavien-Dindo classification. Functional outcomes were excluded. Temporal changes in surgical technique and perioperative protocols were analysed in relation to trends in complications. A total of 199 complications were recorded, with an overall complication rate of 18.2%. Most complications were low-grade, while major complications (Grade ≥ III) occurred in a minority. The most frequent complications included urinary tract infection (4.5%), urinary retention (3.5%), and incisional hernia (3.15%). Symptomatic lymphocele occurred in 0.89% and urethral stricture in 0.98%. Life-threatening complications were rare (0.3%), with one perioperative mortality (0.1%). Few targeted technical modifications were introduced during the study period, including oral antibiotic prophylaxis to prevent urinary tract infections, adoption of a Pfannenstiel incision for specimen extraction to reduce hernia rates, implementation of peritoneal distraction with the aim of reducing lymphocele rates, and optimization of catheter management protocols. These changes were associated with a reduction in procedure-specific complications over time. Although functional outcomes are routinely emphasized, non-functional surgical complications should also be addressed during preoperative counselling. In this large series, most complications were infrequent and manageable, with rates influenced by ongoing technical refinements. While lymphocele and urinary retention may be more frequent with the Retzius-sparing approach, a lower incidence of de novo inguinal hernia was observed. Targeted technical modifications, including Pfannenstiel specimen extraction and oral cefixime prophylaxis, were associated with reductions in specific postoperative complications, highlighting the importance of continuous refinement of surgical technique and perioperative care in optimizing outcomes following RS-RARP.

Objective This study investigates the relationship between body mass Index (BMI), hernia defect diameter, and early postoperative complications in total extraperitoneal (TEP) hernia repair. Methods Of 306 patients undergoing endoscopic inguinal hernia repair between January 2022 and December 2024, 285 patients with completed TEP procedures performed by a single surgeon constituted the final study cohort. Patients were stratified by BMI and hernia defect size. Early postoperative complications within 30 days, including seroma and hematoma, were recorded. Multivariable logistic regression analysis was conducted to identify independent predictors of early complications. All analyses were performed using SPSS version 26.0. Results Within the 30-day postoperative period, seroma occurred in 36 patients (12.6%) and hematoma in 21 patients (7.4%). Obesity (BMI ≥30 kg/m2) was independently associated with increased odds of early postoperative complications (OR 2.8, 95% CI 1.3-5.9, p = 0.02), whereas overweight BMI was not statistically significant (OR 1.2, 95% CI 0.6-2.4, p = 0.34). Hernia defect size ≥25 mm was also identified as an independent predictor (OR 2.9, 95% CI 1.4-6.1, p = 0.03). Age >65 years showed a non-significant trend toward higher complication risk (p = 0.08). Conclusion Obesity and large hernia defects are independent predictors of early complications following TEP hernia repair. Focusing on these factors during preoperative planning may enhance patient safety and outcomes.

Simulation-based education is a valuable tool in paediatric surgery. Inguinal hernias are a common paediatric surgical presentation with an incidence of 1-5% in full-term infants. While previous simulators have been created for adult inguinal hernias and laparoscopic paediatric inguinal hernias, there are limited models for the open paediatric procedure. We aimed to create and validate a simulator for a paediatric open inguinal hernia repair. Essential procedural steps of an open inguinal herniotomy were determined, and a low-cost paediatric simulator was developed. Novices (medical students) and experts (paediatric surgeons) were recruited. A questionnaire on an 11-point Likert-type scale assessed face validity, content validity, and functional task alignment. Median scores > 7.0/10.0 were deemed valid. The total number and type of procedural errors were assessed to determine construct validity. Statistical analysis included Fisher's exact test, a p-value < 0.05 was considered significant. A total of 34 participants were recruited (expert:10, novice:24). The simulator received favourable median scores in the following content validity domains: useful for surgical trainees (7.0/10.0), useful to train open surgical skills (7.5/10.0), and logical flow of procedural steps (9.0/10.0). It was not deemed a valuable training tool for experts (2.0/10.0). The simulator had median scores below 7.0/10.0 for face validity domains, including its tissue and visual realism. Construct validity was demonstrated by novices making more errors on the simulator, p = 0.02. This low-cost open inguinal herniotomy simulator demonstrated content validity, construct validity, and a high degree of functional task alignment.

Reduced pain and discomfort after surgical repair of inguinal hernia in infants: secondary outcome analysis of the randomized controlled HERNIIA-trial.

Assessment of postoperative outcomes of LAT-HSL in the treatment of unilateral inguinal hernia in boys: A multicenter prospective randomized controlled study.

Race and Sex Differences in Postoperative Outcomes After Incarcerated and Strangulated Hernia Repair.