Pediatric Hernia Research Articles

Evaluation of the Role of Ultrasonography in Predicting a Metachronous Contralateral Inguinal Hernia in Children

Abstract Background Inguinal hernia remains one of the most common surgical disorders in children. Almost all pediatric hernias are indirect. The incidence of pediatric inguinal hernia is highest during the first year of life and then gradually decreases thereafter. The incidence of contralateral occurrence of an inguinal hernia after unilateral herniorrhaphy has been reported as 5.6 to 22%. The management of the contralateral inguinal hernia in a child with unilateral CIH has been always debated. Routine contralateral exploration of the inguinal canal has been practiced by many surgeons. Routine contralateral exploration may be associated with a high incidence of negative exploration and lengthening of the operative time in addition to possible increasing morbidity in those patients. Aim of the Work This study aims to evaluate the role of preoperative assessment by ultrasonography in predicting contralateral inguinal hernia in children with unilateral inguinal hernia without clinical evidence of contralateral inguinal hernia. Patients and Methods Fifty infants and children presented to pediatric surgery clinic at Ain Shams University and Nasr City Health Insurance Hospitals aged 1 month till 12 years of age complaining of unilateral inguinal hernia without clinical evidence of contralateral inguinal hernia underwent preoperative US. Results Cases with a width of the contralateral side >3.5 mm at the level of the internal ring determined using the US are likely to be at high risk of developing a contralateral hernia with a sensitivity of 80.0%, specificity of 77.5%, and area under the curve (AUC) of 78.4%. Conclusion Ultrasonography is a rapid, sensitive, convenient, and non-invasive method for screening patients with contralateral occult CIH. It is a reliable tool for preventing unnecessary exploration or additional operations at a later stage. It can be performed in all cases of inguinal hernia to determine the necessity for contralateral exploration. Children having a width of contralateral side >3.5 mm at the level of the internal ring determined using the US are likely to be at high risk of developing a contralateral hernia with a sensitivity of 80.0%, specificity of 77.5%, and area under the curve (AUC) of 78.4%.Therefore, we recommend routine preoperative use of ultrasonography for all patients with unilateral CIH to determine which patient should be subjected to a contralateral exploration.

Laparoscopic inguinal hernia repair in children: true herniotomy is more reliable than herniorrhaphy

BACKGROUND: The optimal laparoscopic technique for pediatric inguinal hernia continues to be discussed with a view to its further refinement. AIM: This study aimed to ascertain the outcomes of two laparoscopic fully intra-corporeal techniques employed in our practice: herniorrhaphy and true herniotomy. METHODS: A retrospective comparative review of patient outcomes was conducted following laparoscopic groin hernia repair: herniorrhaphy — 1st series and true herniotomy — 2nd series. Patient data was analysed using non-parametric statistics with Mann-Whitney test. RESULTS: In total there were 328 patients, aged between 2 months and 17 years, with 402 groin hernia defects including metachronous and rare defects. The herniorrhaphy was performed for indirect hernia defects (n=186) and herniotomy — for indirect (n=206) as well as for direct (n=6) and femoral (n=2) defects. Technically, there were no intraoperative complications in any case in either series. Conversion to open procedure was required in one patient of 1st series (0,5%) with giant hernia because of the impossibility to maintain due pneumoperitoneum. The postoperative recovery was prompt and uneventful with restoration of mobility and oral intake within 3–6 hours in all patients with no difference between the series. Adverse postoperative events were noted in 10 patients after herniorrhaphy — hydrocele (n=6; 3.2%) and hernia recurrence (n=4; 2.2%) whereas after herniotomy there was only one case (n=1; 0.5%) of hydrocele and none of recurrence. The overall rate of these complications was significantly lower in the herniotomy series vs herniorrhaphy (p=0.004). CONCLUSION: Laparoscopic intracorporeal techniques both herniorrhaphy and true herniotomy are safe and effective for pediatric hernia repair. True herniotomy appears to be a more robust technique to minimise incidence of postoperative hydrocele and recurrence.

Laparoscopic Sac Disconnection and Peritoneal Closure of Pediatric Inguinal Hernia.

Background: Laparoscopic sac disconnection and peritoneal closure represents an alternative to open pediatric hernia repair. We performed a retrospective review of our data to evaluate this alternative method. Materials and Methods: With REB approval, a retrospective chart review of all patients who underwent laparoscopic indirect inguinal hernia repair between June 2013 and July 2016 was conducted. Primary outcome was the recurrence rate. Secondary outcomes included length of surgery, postoperative hydrocele, and perioperative complications. Data were extracted from EPIC Hyperspace onto a standardized data extraction form. Results: A total of 243 patients were included, of which 82% were males. Age ranged from 1 month to 17 years of age. A total of 322 defects were repaired. Eighty (32%) had contralateral patent processus vaginalis. Twelve (4%) patients presented with incarceration and three (1.2%) had a direct inguinal hernia defect. Recurrence rate was 0.6% (n = 2). There were no intraoperative complications. Operative time was an average of 40 and 54 minutes for unilateral and bilateral repairs, respectively. No testicular ascents, testicular atrophy, vas deferens injury, postoperative hydroceles, and wound infections were reported. Conclusion: Laparoscopic sac disconnection and peritoneal closure of pediatric inguinal hernia is a safe, feasible method with one of the lowest reported recurrence rate among the other laparoscopic methods.

Is the double-ligation method safe and effective in laparoscopic paediatric inguinal hernia repair? A retrospective cohort study.

Laparoscopic paediatric hernia repair has since been performed more frequently. Recently, a double-ligation method was introduced to prevent recurrence in laparoscopic surgery. The objective of our study was to compare the postoperative outcomes of patients who underwent double and single ligations. We performed a retrospective review of patients with inguinal hernia who underwent laparoscopic paediatric inguinal hernia repair from 2014 to 2018 at our institution. Patients were divided into two groups and underwent single ligation and double ligation. Three hundred and six patients (single-ligation group: 142 and double-ligation group: 164) were included. Four patients experienced recurrence, and the recurrence rate was 1.29%. The recurrence rate was significantly higher in the single-ligation group. There were no statistically significant differences in the postoperative complications between the two groups. Double-ligation method in laparoscopic paediatric hernia repair was relatively safe and helpful.

Analgesia strategy for inguinal hernia repair in children: a systematic review and network meta-analysis of randomized clinical trials based on regional blocks.

Despite its acknowledged benefits, the selection of an optimal regional block for analgesia pediatric hernia surgery remains a subject of debate. This study endeavored to conduct a network meta-analysis and systematic review of randomized clinical trials, aiming to amalgamate insights from both direct and indirect comparisons concerning the analgesic effectiveness and safety of various regional blocks post-inguinal hernia repair in children. A comprehensive literature search was performed across PubMed, EMBASE, Web of Science, and the Cochrane Library up to 12 November 2022 by two independent reviewers, employing a standardized protocol. The inclusion criteria encompassed randomized trials focusing on children undergoing inguinal hernia repair utilizing either local infiltration analgesia or regional analgesia. The primary outcomes assessed were pain scores at 2, 6, and 24 h post-operation. The initial search yielded 281 records relating to 1,137 patients. The analysis of ranking probability indicated that Paravertebral Block (PVB) holds the highest likelihood (88% and 48%) of being the most effective in alleviating pain at 2 h and 6 h post-surgery. Trans vs. Abdominis Plane Block (TAPB) emerged as the superior choice for mitigating pain (83%) and decreasing morphine consumption (93%) at 24 h following the operation. Local Anesthetic Infiltration (LAI) was identified as the most effective in shortening the hospital stay, with a 90% probability. Regional anesthesia significantly enhances postoperative pain management in pediatric inguinal hernia repair surgery. For short-term postoperative pain relief, PVB emerges as the most effective technique. Meanwhile, TAPB provides more prolonged analgesia. Although TAPB does not exhibit a pronounced advantage in short-term analgesia, its simplicity and the absence of a need for a special position render it a viable option. However, the interpretation of these results should be approached with caution due to the presence of limited data and heterogeneity. PROSPERO (CRD42022376435; www.crd.york.ac.uk/prospero).

Percutaneous Internal Ring Suturing A minimally invasive procedure in pediatric inguinal hernia repair

Percutaneous internal ring suturing (PIRS) is a single-port laparoscopic technique to repair a pediatric indirect inguinal hernia. We used PIRS in our babies and found that the surgery time was shortened, with smaller incisions, lesser complications, and early discharges. This is a retrospective case study to introduce our novel minimally invasive method of repairing pediatric hernias with fewer complications, safe and cost-effective.

Robotic repair of pediatric hernias: Current techniques and practices

The use of minimally invasive surgical techniques has gained popularity in pediatric surgery due to decreased length of stay, improved post-operative pain and smaller incisions. Laparoscopic assisted robotic surgical procedures are becoming more common in adults as they carry all of the benefits of traditional MIS but also allow for improved dexterity, visualization and surgeon ergonomics. In adults, hernia repairs are one of the most commonly performed robotic cases but adaption to pediatric repairs has been slower. Case reports and small case series have described a number of various types of pediatric hernia repairs including congenital diaphragmatic hernias, paraesophageal hernias and inguinal hernias. These cases have demonstrated that robotic repair of pediatric hernias is safe and feasible with minimal documented post-operative complications or recurrence. Future directions should focus on larger patient volume in order to assess outcomes between traditional laparoscopic and robotic approaches.

Analysis on the Application Value of Humanistic Care in Nursing Care of Pediatric Hernia Surgery under Laparoscope

Analysis on the Application Value of Humanistic Care in Nursing Care of Pediatric Hernia Surgery under Laparoscope

Antimicrobial Prophylaxis for Urologic Procedures in Paediatric Patients: A RAND/UCLA Appropriateness Method Consensus Study in Italy.

The main aim of surgical antimicrobial prophylaxis (SAP) in urologic procedures is to prevent bacteraemia, surgical site infections (SSIs), and postoperative urinary tract infections (ppUTIs). Guidelines for SAP in paediatric urology are lacking. Only some aspects of this complex topic have been studied, and the use of antibiotic prophylaxis prior to surgical procedures seems to be more often linked to institutional schools of thought or experts’ opinions than to rules dictated by studies demonstrating the most correct and preferred management. Therefore, the aim of this Consensus document realized using the RAND/UCLA appropriateness method is to provide clinicians with a series of recommendations on SAP for the prevention of bacteraemia, SSIs, and ppUTIs after urologic imaging and surgical procedures in paediatric patients. Despite the few available studies, experts agree on some basilar concepts related to SAP for urologic procedures in paediatric patients. Before any urological procedure is conducted, UTI must be excluded. Clean procedures do not require SAP, with the exception of prosthetic device implantation and groin and perineal incisions where the SSI risk may be increased. In contrast, SAP is needed in clean-contaminated procedures. Studies have also suggested the safety of eliminating SAP in paediatric hernia repair and orchiopexy. To limit the emergence of resistance, every effort to reduce and rationalize antibiotic consumption for SAP must be made. Increased use of antibiotic stewardship can be greatly effective in this regard.

Clinical observation of equivalent dose of diazocine or fentanyl combined with sevoflurane total inhalation anesthesia in pediatric hernia surgery.

article: Clinical observation of equivalent dose of diazocine or fentanyl combined with sevoflurane total inhalation anesthesia in pediatric hernia surgery - Minerva Pediatrics 2022 August;74(4):497-9 - Minerva Medica - Journals

Raymond A Dieter, Jr. MD MS

Raymond A Dieter, Jr. MD MS

P067 HUMANITARIAN HERNIA SURGERY - 10 YEARS OF PERSONAL EXPERIENCE AND THE SAFETY OF LDPE MOSQUITO MESH

Abstract Aim Many people from low-income countries suffer from late or no treatment of incarcerated hernias. That can cause permanent consequences or even death. Hernia International is a 100% volunteer organisation, delivering humanitarian hernia surgery in the countries of the third world. A LDPE mosquito mesh is widely used. Its safety and full functionality was described. Material and Methods A LDPE Mosquito mesh was a subject of testing for a heavy metal content; the same-size piece of a mosquito mesh, and a standard commercial mesh, were tested by spectral photometry. I have had the chance to join 11 international voluntary teams in the years of 2011-2019. More than 1000 procedures were performed, including large inguinoscrotal, incisional, and pediatric hernias. The conditions were often very basic, and a LDPE mosquito mesh and local anaeshesia were used in most adult cases. Results The test shows comparable or less presence of heavy metals in the LDPE mosquito mesh, in comparison with a standard polypropylene mesh. A very low number of early post-op complications, such as haematoma and wound infection, were recorded (less than 1%) in a group of patients operated during voluntary missions. 1-2 local young surgeons were trained in basic hernia procedures. Conclusions Hernia International provides a high-quality surgical care to the patients from the developing countries. Using a mosquito mesh is a safe and effective method with a comparable low complication rate but with minimal costs.

EP.TH.919Developing A Fast Track Paediatric Herniotomy Service In A District General Hospital

Abstract Introduction Previously to 2011, babies presented as emergency to our Trust with irreducible inguinal hernia at a rate of 1 baby/year. They were referred to our regional tertiary centre for surgery because there is no out of hours Paediatric Surgeon or Anaesthetist. Usually, patients were either, awaiting an appointment to see surgeon or on an 18-week waiting list. The aims of this SIP were to: expedite elective surgery for paediatric inguinal hernias, and prevent emergency paediatric inguinal hernia referrals to our tertiary centre. Method Referrals to paediatric surgical clinics were triaged by the clinic sister. Hernia referrals were expedited to the next available clinic. A provisional date for surgery was arranged ASAP with an identified surgeon and anaesthetist whilst in clinic. Patient demographics and data collected retrospectively. Results A 73% reduction in waiting time for surgery, 1 baby (1.4%) presented as emergency and was referred to our tertiary centre for surgery, the post-op complication rate fell from 6.5% to 0%. Conclusion The success of the fast-track paediatric herniotomy service at our DGH shows that it is possible to provide timely and safe surgery in a DGH in line with the recommendations of the Paediatric Critical Care and Surgery in Children Review (November 2019).

Results of using the method of full extraperitoneal endoscopically assisted ligation of the hernial sac with inguinal hernia in children

Background/PurposeThe aim of this study was to evaluate the effectiveness of a new technique for inguinal hernia repair in children: pediatric hernia extra-peritoneal ligation and percutaneous suturing (PHELPS) in comparison with another laparoscopic technique, subcutaneous endoscopically assisted ligation (SEAL). MethodsWe demonstrate the results of laparoscopic treatment of 680 patients with inguinal hernias. Of these, 206 patients were operated using the new PHELPS technique. The remaining 474 children received the SEAL technique. The difference between the methods is that PHELPS consists of ligating the hernia around the neck of the hernial sac, including an intra-peritoneal component (aponeurosis and muscles), while the SEAL technique ligates the hernia sac only. We examined whether this factor may lead to more recurrence and hydrocele in the SEAL technique. ResultsBoth groups of patients were comparable in terms of age, body weight at the time of surgery, and gender. The average total duration of inguinal herniorraphy, including the time of surgery in patients with one-and two-sided hernia localization, was comparable in both groups (17.50 min versus 17.22 min; p = 0.518). The study demonstrated a faster recovery of patients after using the PHELPS technique for the treatment of inguinal hernias, consisting in a statistically significantly lower number of doses of postoperative analgesia (1.01 versus 1.31; p < 0.001) and a shorter time of patient stay in the hospital (8.06 h versus 8.78 h; p = 0.031). Despite the fact that there were no statistically significant differences in the frequency of postoperative hydrocele (0 versus 6; p = 0.090), we found a statistically significant difference between the groups in terms of recurrence (0 versus 17; p < 0.001). ConclusionsThe PHELPS technique shows improved results in terms of recurrence and hydrocele as compared to SEAL. Level of EvidenceLevel III Type of studyRetrospective Comparative Study

Comparison of Postoperative Pain and Analgesic Requirements Between Laparoscopic and Open Hernia Repair in Children

BackgroundThis study analyses the impact of anaesthetic blockade and intraperitoneal local anaesthetic infiltration on paediatric laparoscopic inguinal hernia repair.MethodA retrospective review of paediatric laparoscopic hernia repairs versus open repairs. Anaesthetic blockade, analgesic consumption and postoperative pain scores were compared between groups.Results155 children underwent laparoscopic repair, 150 underwent open repairs. Median age was 7.2 months (16 days–14 years) in the laparoscopic group, 6 months (17 days–13 years) in the open group. Anaesthetic blockade varied significantly; 62.7% of open cases had caudal blockade compared to 21.6% laparoscopic (p < 0.001). A subset of laparoscopic patients had peritoneal local anaesthetic infiltration. 10.1% of laparoscopic cases required recovery analgesia, compared to 1.3% of open cases (p = 0.001). Postoperative analgesic consumption was significantly higher in the laparoscopic group. Peritoneal infiltration reduced analgesic consumption in the laparoscopic group (p = 0.038). Age < 2 was associated with use of caudal (p < 0.001), which reduced analgesic consumption.ConclusionsLaparoscopy was associated with increased use of recovery analgesia. Caudal reduced the need for rescue and postoperative analgesia. Intraperitoneal infiltration of local anaesthetic is associated with reduced postoperative analgesia in laparoscopy. In suitable patients undergoing laparoscopic surgery, combination caudal and peritoneal infiltration may prove a useful adjunctive analgesic strategy.

A Randomised Controlled Trial to Assess the Analgesic Efficacy of Reduced Dose 0.2% Ropivacaine-Dexmedetomidine Combination Compared to Standard 0.375% Ropivacaine in USG Guided TAP Block for Paediatric Hernia Repair.

Paediatric pain management has remained understated practice over a period of time. Recently ultrasound-guided (USG) guided techniques are gaining popularity for perioperative analgesia, especially in the paediatric population. So, the aim of the present study was to evaluate the efficacy of reduced dose ropivacaine-dexmedetomidine combination compared to standard 0.375% ropivacaine in USG guided transversus abdominis plane (TAP) block. Sixty children of either sex, aged 2-10 years, posted for elective open herniotomy under general anaesthesia were randomly divided into two groups of 30 patients each. Group RD received 0.2% ropivacaine with dexmedetomidine 1 mg kg 1 while group R received 0.375% ropivacaine at 0.5mL kg 1. Meantime to first rescue and total analgesics, Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Ramsay sedation score, haemodynamic parameters and adverse effects were noted. Time to first rescue analgesia in group RD and group R were 16.32 6 3.11 hours and 10.82 6 2.16 hours, respectively (P < .0001). Mean CHEOPS score were 4.48 6 1.1 and 6.3 6 1.74 (P < .024) in group RD and R. Post-op Ramsay sedation score was significantly greater in group RD. Heart rate and blood pressure remained similar in either of the group. No episode of respiratory depression, bradycardia or hypotension was noted perioperatively. Combination of 1 mg kg 1 dexmedetomidine with reduced concentration of ropivacaine (0.2%) produced significantly longer duration of post-operative analgesia and lowered post-operative CHEOPS pain score in comparison with 0.375% ropivacaine alone in USG guided TAP block for paediatric hernia repair.

Learning Curve for Laparoscopic Repair of Pediatric Inguinal Hernia Using Percutaneous Internal Ring Suturing.

Background: Percutaneous internal ring suturing (PIRS) is a simple and popular technique for the treatment of inguinal hernia in children. The aim of this study was to analyze the learning curves during implementation of PIRS in our department. Methods: A total of 318 pediatric patients underwent hernia repair using the PIRS technique by three pediatric surgeons with different levels of experience in laparoscopic surgery. These patients were enrolled in a prospective cohort study during the period October 2015–January 2021. Surgical times, intraoperative and postoperative complications, in addition to outcomes of treatment were compared among the pediatric surgeons. Results: Regarding operative time a significant difference among the surgeons was found. Operative time significantly decreased after 25–30 procedures per surgeon. The surgeon with advanced experience in laparoscopic surgery had significantly less operative times for both unilateral (12 (interquartile range, IQR 10.5, 16.5) min vs. 21 (IQR 16.5, 28) min and 25 (IQR 21.5, 30) min; p = 0.002) and bilateral (19 (IQR 14, 21) min vs. 28 (IQR 25, 33) min and 31 (IQR 24, 36) min; p = 0.0001) hernia repair, compared to the other two surgeons. Perioperative complications, conversion, and ipsilateral recurrence rates were higher at the beginning, reaching the benchmarks when each surgeon performed at least 30 PIRS procedures. The most experienced surgeon had the lowest number of complications (1.4%) and needed a fewer number of cases to reach the plateau. The other two surgeons with less experience in laparoscopic surgery had higher rates of complications (4.4% and 5.4%) and needed a higher number of cases to reach the plateau (p = 0.190). Conclusions: A PIRS learning curve for perioperative and postoperative complications, recurrences, and conversion rates reached the plateau after each surgeon had performed at least 30 cases. After that number of cases PIRS is a safe and effective approach for pediatric hernia repair. A surgeon with an advanced level of experience in pediatric laparoscopic surgery adopted the technique more easily and had a significantly faster learning curve.

AB077. SOH21AS055. Laparoscopic paediatric herniotomy in Ireland: the first 100 cases and its application to adults

Background: Inguinal hernias are common in childhood. Minimally invasive approaches have been adopted by centres internationally as comparable to open repair. We report the initial Irish experience of laparoscopic paediatric hernia repair in children up to age 16 using a purse string closure of the deep inguinal ring.

Laparoscopic Inguinal Hernia Repair in Children: To Cut or Not to Cut is the Question?

Context:Laparoscopic repair of pediatric inguinal hernia is gaining popularity, however there is no consensus about the technique of operation.Aims:The aim of the study was to compare the results and complications of two techniques of laparoscopic pediatric hernia repair.Settings and Design:This retrospective study was conducted at the Department of Pediatric Surgery in All India Institute of Medical Sciences (AIIMS), Jodhpur.Subjects and Methods:All children who underwent laparoscopic inguinal hernia repair at AIIMS, Jodhpur, during the period of September 2016–March 2019 were retrospectively studied. Parameters studied included age, gender, side of hernia, technique used, operating time, complications, and hospital stay. Patients were divided into two groups depending on whether the hernial sac was divided or not divided before taking a purse-string suture.Statistical Analysis Used:Student's t-test and Fischer exact test were used to analyze data.Results:A total of 114 patients were included in the study. The median age was 36.4 months. Hernial sac was divided before suturing in 53 patients, while sac was left intact in 61 patients. The mean follow-up was 11.4 months (range: 4–16). Age, gender, side of hernia, complications, and hospital stay were comparable in both groups. There was a significant difference between the mean operating duration in patients who underwent division of hernia sac compared to patients in whom the sac was not divided before putting purse-string suture (92.5 min [45–150] vs. 65.7 [30–90], respectively, P = 0.0101). Hernia recurrence (3.8% in Group A vs. 1.6% in Group B) was comparable in the two groups.Conclusions:Laparoscopic pediatric hernia repair done with or without dividing the peritoneal sac gives comparable results, however operative duration is less if sac is not divided.

Incidence of Inguinal Herniotomy in Children. A Prospective Study at a Regional Hospital

Background: Inguinal hernia is one of the most common surgical conditions in children. Herniotomy is the surgery performed for a pediatric hernia and hydrocele. This study was done to know the demography and outcome of pediatric herniotomy at our center. &#x0D; Materials and methods: A prospective study on patients who underwent herniotomy from 10th May 2016 to 9th May 2017 was conducted at the Department of Surgery, Western Regional Hospital. &#x0D; Results: During this study 112 patients underwent herniotomy out of which 98 were boys while 14 were girls. 59(52.67%) patients had unilateral hernia, 40(35.71%) had unilateral hydrocele and 13(11.6%) had bilateral condition among which 8 had hernia and 5 had hydrocele. 69(61.6%) patients presented with a right-sided, 30(26.7%) with left-sided, and 13(11.6%) with bilateral conditions. 13 patients (11.6%) presented at the emergency with irreducible hernia. Two among the patient who underwent emergency herniotomy developed postoperative wound infection and one among the elective surgery had recurrence. &#x0D; Conclusion: Pediatric inguinal hernias and hydroceles are often difficult to diagnose clinically. Herniotomy is often performed by junior consultants who have no specific training in pediatric surgery. Timely planning of surgery is required to minimize preoperative complications.