Pediatric Inguinal Hernia Research Articles

Pediatric Laparoscopic Inguinal Hernia Repair: A Comparison between Techniques

Background: Traditionally in herniotomy, indirect hernial sac is dealt by high ligation and removal of the redundant part, to avoid recurrence. However, some authorities are of the opinion that excision of the hernial sac without ligation is not associated with recurrence of the hernia. Some have even shown adverse events related to hernial sac ligation like increased post-operative pain and discomfort. There is no consensus on how the hernial sac should be managed during laparoscopic herniotomy.
 Objectives: Present study aimed to determine the feasibility of laparoscopic sac excision without ligation in pediatric age group, by a randomized comparison.
 Materials and methods: This interventional study was performed in the department of Paediatric Surgery, Rajshahi Medical College Hospital, Rajshahi, Bangladesh, over a period of one year. A total of 189 patients were included in the study as per inclusion and exclusion criteria and randomized in the three groups. Comparisons were made among three procedures of laparoscopic herniotomy, namely; Percutaneous extraperitoneal closure, Intraperitoneal purse-string closure and laparoscopic sac excision without ligation. The main outcome measures were recurrence rate, operative time, hospital stay, postoperative hematoma and hydrocele formation. Results: Recurrence rate, operative time and hospital stay were not amplified in laparoscopic sac excision procedure than others. Postoperative hydrocele formation was significantly less.
 Conclusion: Laparoscopic sac excision in indirect pediatric inguinal hernia is safe. The procedure is not associate
 TAJ 2020; 33(2): 20-26

Evaluasi Rekurensi Laparoskopi-assisted Ligasi Ekstraperitoneal dengan Penggunaan IV Catheher 18G pada Pengobatan Hernia Inguinalis Anak

Treatment of pediatric inguinal hernia can be done with conventional and laparoscopy methods. Laparoscopic percutaneous extraperitoneal ligation closes the internal inguinal ring by making sutures that are knotted by the extraperitoneum and implanted in the subcutaneous tissue. The rate of recurrence and postoperative complications are still a major concern. Division of pediatric surgery at Dr. M.Djamil Hospital Padang made modifications using an 18G intravenous catheter that was bent to form an angle of 100-150. This study aims to determine the success of laparoscopic herniotomy with modification performed by recurrence rate. This study is a retrospective analytic design method. Data was taken from the medical record status of pediatric inguinal hernia patients undergoing laparoscopic herniotomy at RSUP Dr. M.Djamil Padang from January 2018 -December 2019. Data were analyzed by crosstabulation using the Fisher test. Recurrence was seen in 7,4% of patients (5/68 patients). Three cases in boys and 2 cases in girls. Two cases in the age group ≤1 year and 3 cases in the age group >1 year. One case in the weight group ≤10 kg and 4 cases in the bodyweight >10 kg. Three recurrent cases appeared on the right side and 2 cases on the left side. There were no differences in the incidence of recurrence after laparoscopic-assisted extraperitoneal ligation with intravenous catheter 18G as needle puncture according to age, sex, body weight, and location of the hernia.

Derivation of a complication burden score based on disability-adjusted life years to assess patient burden following surgery: a pilot study

Comparing adverse outcomes following alternative surgical interventions is a complex process for both patients and providers. Disability-adjusted life years (DALYs) are used globally as a quantitative indicator of burden of disease. However, DALYs have not been applied to the burden of postoperative complications. This study explores the feasibility and utility of DALYs in measuring the burden of postoperative complications, using 2 pediatric surgical procedures as a test model. A literature review was undertaken of postoperative complications following pediatric inguinal hernia repair and intestinal atresia repair. Relevant studies were included, and incidence rates and durations of all key complications were identified. Using existing disability weights of equivalent health states to the complications, we estimated the burden in DALYs of each complication. These estimates were combined into a unitary procedure-specific complication burden score. The key complications contributing to the postoperative burden following inguinal hernia repair were recurrence (0.016 DALYs), hydrocele (0.010), metachronous hernia (0.014) and port-site hernia (0.012). In the case of intestinal atresia repair, death (6.278), reoperation (12.100), stenosis (5.025) and anastomotic stricture (5.327) accounted for most of the postoperative DALYs. The complication burden score was 0.06 DALYs for inguinal hernia and 36.86 for intestinal atresia repair. As a proof of concept, this study supports the feasibility of using DALYs to derive a complication burden score following surgical intervention, and to our knowledge it represents the first application of burden of disease metrics to postoperative adverse outcomes. Future studies should focus on deriving de novo disability weights for common postoperative complications and adverse outcomes.

Percutaneous Internal Ring Suturing for the Minimal Invasive Treatment of Pediatric Inguinal Hernia: A 5-Year Single Surgeon Experience.

Percutaneous internal ring suturing (PIRS) is a minimally invasive surgical technique of laparoscopic hernia repair in children under the control of a laparoscope placed in the umbilicus. The aim of this study was to evaluate the management and postoperative outcomes of PIRS for inguinal hernia repair in children. All children who underwent PIRS for an inguinal hernia, between February 2015 and February 2020, were included in the prospective cohort study. The following parameters were recorded: age, gender, body mass index, lateralization of hernia, surgical and anesthesia times, level of pneumoperitoneum, additional trocar introduction, length of hospital stay, and intraoperative or postoperative complications and recurrences were recorded. A total number of 228 PIRS procedures were performed in 188 children [126 (67%) male individuals and 62 (33%) female individuals] with a median age of 4 [interquartile range (IQR), 2 to 6] years and a median follow-up of 46 (IQR, 38 to 52) months. From the total number of hernia repairs there were 99 (52.7%) right, 49 (26.1%) left, and 40 (21.2%) bilateral hernia repairs. Median surgical time was 10 (IQR, 8 to 12) minutes for unilateral and 16 (IQR, 14 to 20) minutes for a bilateral repair. The median hospital stay was 24 (IQR, 8 to 24) hours. Regarding intraoperative complications, only 3 (1.3%) inferior epigastric veins injuries were recorded, without any consequences. During the follow-up period in 3 male children, hydrocele was recorded; in 2 cases, hydrocele resolved spontaneously and 1 required surgical treatment. No cases of other complications including testicular atrophy or recurrence were recorded. In a hands of an experienced pediatric laparoscopic surgeon, PIRS is a simple, safe, and effective technique for inguinal hernia repair in children with excellent outcomes, cosmetic results, and a low incidence of complications and recurrence.

Initial Results of Single-Incision Laparoscopic Surgery for Pediatric Inguinal Hernia in Our Hospital

Initial Results of Single-Incision Laparoscopic Surgery for Pediatric Inguinal Hernia in Our Hospital

Laparoscopic iliopubic tract repair for pediatric inguinal hernia has very low recurrence: an Indian experience

BackgroundThe aim of this study is to document results of laparoscopic iliopubic tract (IPT) repair for inguinal hernia in the pediatric age group.MethodsHospital records of 190 children who underwent IPT...

Single-Incision Percutaneous Closure of Pediatric Inguinal Hernia: A New Modification for Intracorporeal Suture Knotting.

Background Single-incision percutaneous closure (SIPC) of pediatric inguinal hernia under laparoscopic guidance is a well-developed feasible technique; however, suture knotting remains a major challenge during this technique. Most laparoscopic surgeons prefer extracorporeal subcutaneous suture knotting, which may be associated with consequent formation of stitch sinus and increased recurrence rate. On the other hand, intracorporeal suture knotting necessitates the availability of special devices or homemade instruments with a long learning curve. Therefore, the present study innovates new and simple modification allowing intracorporeal suture knotting during SIPC of pediatric inguinal hernia that does not require any special operating devices or homemade instruments. Patients and Methods. Four-hundred children suffering from inguinal hernia of congenital type, submitted to SIPC using Epidural needle (EN), under laparoscopic guidance with intracorporeal suture knotting. Results Children ages were 6 months to 10 years (the range). There were 300 boys and 100 girls, and two-hundred children suffered from left side hernia, 150 with right-side hernia, and 50 children with both left- and right-side hernia. 10 ± 2.2 minutes was the recorded operation time in one side hernia repair, while 14 ± 4.3 minutes was recorded for both side repair. Postoperative results reported recurrent hernia in one child and postoperative hydrocele in 3 children which resolved spontaneously after 3 weeks of follow-up. Conclusion Intracorporeal suture knotting during SIPC of pediatric inguinal hernia allows for the transformation of a formally extraperitoneal procedure to an intraperitoneal procedure. This new modification for intracorporeal suture knotting does not require any special operating devices or homemade instruments. It seems to be an attractive way during SIPC of pediatric inguinal hernia when intracorporeal suture knotting is considered.

Complications of inguinal hernia repair in children: A tertiary hospital experience

Background: Repair of inguinal hernia is one of the most frequently performed procedures in pediatric surgery. 
 Objective: The aim of this study was to evaluate the complications we encountered following repair of inguinal hernia in children. 
 Methodology: This was a retrospective study done in children aged 15 years and below who had complications following inguinal hernia repair (both emergency and elective) at the pediatric surgery unit of Enugu State University Teaching Hospital (ESUTH) Enugu, Nigeria, between January 2014 and December 2018. 
 Results: A total of 1243 cases of pediatric inguinal hernia repairs were performed during the study period. Out of this, 123 patients developed complications, accounting for 9.9% of the total cases. There was male predominance with a median age of 1 year. Most of the complications were noted in infants undergoing emergency repairs. Scrotal complications were the most common complications which resolved on non-operative treatment. Other complications in descending order of frequency included wound infection, hernia recurrence, testicular atrophy and sensory disturbances in the inguinal region. There was no mortality following the surgeries. 
 Conclusion: Pediatric inguinal hernia repair is a procedure with potential complications more so in infants following an emergency repair. Preoperative parental counseling and timely referral are mandatory.

Laparoscopic assisted percutaneous internal ring suturing for inguinal hernia repair in pediatrics

Several laparoscopic techniques used in treatment of pediatric inguinal hernia differ in their approach to the internal inguinal ring, suturing and knotting techniques, number of ports, endoscopic instruments used and hernia sac dissection technique. The aim of this study was to evaluate efficacy and safety of laparoscopic assisted percutaneous internal ring suturing for inguinal hernia repair in pediatrics. Laparoscopic assisted percutaneous internal ring suturing was performed under general endotracheal anesthesia on 54 children with 64 hernias during the period from July 2018 to June 2019. Under laparoscopic-guided vision a 2-0 Prolene® thread inside an 18-gauge epidural needle was placed through the abdominal wall into the peritoneal cavity, then the thread passed under the peritoneum around the internal ring. The knot was tightened from outside and placed in the subcutaneous space. The mean operative time was 14.18 min for unilateral and 21.2 min for bilateral hernias. Cosmetic results are excellent with almost invisible scars. There were no intraoperative and six postoperative complications (recurrence in three cases, transient hydroceles in two boys and one patient had stitch sinus). Laparoscopic assisted percutaneous needle repair of congenital inguinal hernia seems to be a simple minimally invasive procedure in small ring diameter with excellent cosmetic results. But I do not recommend this technique due to high rate of complications and recurrence, also simplicity of the technique can be regarded as a hindrance to the surgeons in training from challenging their skills to be ready for the more complex scenarios.

The Incidence of Recurrence after Laparoscopic Versus Open Inguinal Hernia Repair in Children: a Systematic Review and Meta-Analysis

Inguinal surgery is one of the most common surgical procedures in children. However, whether laparoscopic hernia repair is superior to open hernia repair remains unclear. To undertake a systematic review and meta-analysis of randomized controlled trials evaluating the recurrence rate after laparoscopic hernia repair and open hernia repair in children who underwent repair for pediatric inguinal hernia. The Web of Science Database, Pubmed, Embase, WanFang Data, China National Knowledge Infrastructure, and Cochrane Central Register of Controlled Trials were searched to identify eligible studies. The outcomes evaluated were the recurrence rates including metachronous contralateral inguinal hernia and the complication rates associated with both laparoscopic hernia repair and open hernia repair. Seventeen RCTs including 2122 children (2540 hernia defects) were analyzed. Methodologic quality was unclear in most trials. The recurrence rate after inguinal hernia repair in children was 1.3% (33/2540). Meta-analysis of randomized trials did not reveal significant difference between the 2 techniques in the incidence of recurrence (relative risk [OR] = 0.48, 95% confidence interval [CI] = 0.12–1.82, P = 0.280). Simultaneously, there were no significant differences between laparoscopic hernia repair and open hernia repair in the incidence of metachronous contralateral inguinal hernia (OR = 0.33; 95% CI, 0.05–2.30; P = 0.270) and postoperative complications (OR = 0.58; 95% CI, 0.20–1.71; P = 0.320). Laparoscopic repair of a Pediatric hernia does not offer significant advantage over open hernia repair, therefore a decision to perform laparoscopic and/or open repair is best left to the surgeon, expertise available and parents in respective geographic area.

Laparoscopic Needle–Assisted Repair for Pediatric Inguinal Hernia

AbstractLaparoscopic needle–assisted repair (LNAR) has recently emerged as a safe and effective alternative procedure to manage pediatric inguinal hernia. However, the literature does not address the case of the efficacy of performing the LNAR by trainees or surgeons with no wide experience in laparoscopy. Therefore, the focus of the present study is to present the results of conducting such a procedure by professionals who do not possess such an experience. In a 12-month period, we performed 18 laparoscopic needle–assisted repairs for indirect pediatric inguinal hernias by one surgeon. We have collected and analyzed data concerning operating time, postoperative course and complications, need for analgesia, recurrence, and cosmetic results. No incidents during surgery have been recorded. Fifteen patients underwent laparoscopic surgery. Two contralateral hernias were intraoperatively diagnosed. Mean time of surgery, mean hospital stay, operating time, the need for postoperative analgesia, and recurrence were close to other studies performed by experts. All procedures were completed laparoscopically. The LNAR is a simple, effective, and safe procedure even when performed by trainees or surgeons without large previous experience in laparoscopy.

Single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) of hernia sac high ligation using an ordinary taper needle: a novel technique for pediatric inguinal hernia.

Laparoscopic high ligation of the internal inguinal ring is an alternative procedure for treatment of pediatric inguinal hernia (PIH), with a major trend toward increasing use of extracorporeal knotting and decreasing use of working ports. We have utilized this laparoscopic technique to treat the entire spectrum of PIH (including incarcerated cases) for more than 17years, and the technique continues to evolve and improve. We herein report our latest modification of this minimally invasive technique, namely single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) of hernia sac high ligation using an ordinary taper needle, and evaluate its safety and efficacy. From July 2016 to July 2019, 790 children with indirect PIH were treated by laparoscopic surgery. All patients underwent high ligation surgery with a modified single-site laparoscopic technique mainly performed by extracorporeal suturing with an ordinary closed-eye taper needle (1/2 arc 11 × 34). The clinical data were retrospectively analyzed. All surgeries were successful without serious complications. A contralateral patent processus vaginalis (CPPV) was found intraoperatively and subsequently repaired in 190 patients (25.4%). The mean operative time was 15min (8-25min) for 557 unilateral hernias and 21min (14-36min) for 233 bilateral hernias. The mean postoperative stay was 20h. Minor complications occurred in five patients (0.63%) and were managed properly, with no major impact on the final outcomes. No recurrence was noted in the patients who were followed up for 6-42months. No obvious scar was present postoperatively. Modified SLPEC of hernia sac high ligation using an ordinary taper needle for repair of indirect PIH is a safe, reliable, and minimally invasive procedure with satisfactory outcome, with no special device being needed. It is easy to learn and perform and is worthy of popularization in the clinical setting.

Short-term outcomes of pediatric laparoscopic inguinal hernia repair in Korea based on Korean Health Insurance Big Data: 2011-2015.

For pediatric inguinal hernia repairs (IHRs), open IHR (high ligation) has long been a gold standard. Recently laparoscopic IHR (LIHR) was introduced as a new treatment modality and has been performed more frequently in Korea. Unlike adults, LIHR in children is still controversial. In the present study, we investigate the short-term outcomes of pediatric LIHR in Korea using nationwide inpatient data. We analyzed clinical practice for IHRs from 2011 to 2015 using Korean Health Insurance Review and Assessment Service-National Inpatient Sample. A total of 5281 patients 15years old or younger underwent 5356 IHRs: 4507 OIHRs and 849 LIHRs. M:F ratio was 2.4:1. The proportion of LIHRs was only 1.8% at the beginning but had been continuously increased up to 29.8% at the end of the study period. LIHRs were closely related to synchronous bilateral inguinal hernia repairs (SBIHRs). Overall, SBIHRs were performed in 10.9% of open and 49.2% of LIHRs. Metachronous contralateral IHRs (MCIHRs) after initial unilateral IHRs were significantly more frequent after OIHRs (1.7%, 69/3, 951) than after LIHRs (0.2%, 1/427). Recurrence rate per side during study period was 0.1% (6/4, 993) after OIHRs and 0.2% (2/1, 259) after LIHRs, respectively (statistically insignificant). Nationwide inpatient data showed that LIHRs in pediatric patients had recently been increasingly performed in Korea. LIHRs facilitated SBIHRs, which, in turn, decreased the needs of MCIHRs. However limited numbers of patients might actually have benefited from them. Early recurrence after primary IHRs in children is quite low regardless of way of approach.

Laparoscopic Pediatric Inguinal Hernia Repair; Intracorporeal Purse-String Suture Using Needlescopic 2-mm Instruments.

PurposeTwo-millimeter needlescopic instruments induce minimal damage to the abdominal wall and have excellent cosmetic benefits. We aimed to evaluate the feasibility of a laparoscopic intracorporeal suture using 2-mm instruments for pediatric inguinal hernia.MethodsWe retrospectively reviewed 131 patients who underwent laparoscopic repair between March 2011 and February 2017. Three trocars were used: a 5-mm umbilical trocar for a needle holder and two 2-mm trocars for a camera and a grasper. The internal ring was closed with an intracorporeal purse-string suture. A telephone interview was conducted to confirm recurrence.ResultsIn the 131 patients, 169 procedures were successfully performed. The ages ranged from 2 months to 14 years (mean, 52.5 months), and the mean body weight was 18.0 kg (range, 6.7~49 kg). The mean operating time was 42 minutes for the unilateral cases and 46 minutes for the bilateral inguinal hernia repairs. All the cases were completed laparoscopically without intraoperative complications. Herniotomy was not performed in all the patients except nine. A contralateral patent processus vaginalis was present in 27.3% (35/128) of the patients. During the mean follow-up period of 54.6 months, 3 recurrences (2.3%) were observed. Two recurrences were treated using laparoscopy and one using open herniorrhaphy. Hydrocele occurred in one male patient. No wound complications or umbilical hernias developed. No testicular atrophy was observed.ConclusionThis study showed that laparoscopic intracorporeal internal ring suture using 2-mm instruments for pediatric inguinal hernia was technically feasible and safe, with excellent cosmetic results.

Adding iliopubic tract repair to high ligation reduces recurrence risk in pediatric laparoscopic transabdominal inguinal hernia repair.

Many laparoscopic methods are available for treating pediatric inguinal hernias. Recurrence after laparoscopic pediatric inguinal hernia repair (LPIHR) is one of the greatest concerns for surgeons. The present study was performed to evaluate the effects of iliopubic tract repair in LPIHR with respect to the recurrence rate, surgical outcomes, and complications. LPIHR was performed in 3386 pediatric patients aged < 10years from January 2016 to June 2018. The patients were categorized into two groups according to the operative techniques: high ligation alone (1736 patients) and additional iliopubic tract repair (1650 patients). In high ligation surgery, the hernia sac was removed and the peritoneum was closed. In iliopubic tract repair surgery, iliopubic tract and transversalis fascia arch sutures were added. Recurrence only occurred in the high ligation group; no patients in the iliopubic tract repair group developed recurrence [0.35% (6/1736) vs. 0.00% (0/1650), respectively; p = 0.014]. Other surgical outcomes and complications did not differ between the two groups. Six patients in the high ligation group developed recurrence: four infants aged < 1year and two children aged > 1year. The mean duration from the first operation to reoperation in these six patients was 11.8months; five patients developed recurrence within 1year after the initial operation. All patients had a recurrent indirect hernia, and the location of the hernial defects was on the medial side of the previous stitch. The logistic regression indicated that the difference between the two groups affected the recurrence rate. This finding predicted that iliopubic tract repair is associated with a lower recurrence rate than high ligation (odds ratio 0.996, 95% confidence interval 0.994-0.999, p = 0.015). This study of transabdominal LPIHR indicates that iliopubic tract repair results in a small but significant decrease in the risk of recurrence.

Incarcerated and strangulated inguinal hernias in children: A 10-year retrospective analysis

Abstract Background: In pediatric inguinal hernia, the most feared complication is incarceration, which can lead to catastrophic consequences if not resolved expeditiously. Aims: This study assessed the usefulness of manual reduction of complicated inguinal hernia in children. Settings and Design: This study was designed to study the age at presentation, gestation age at birth, duration of symptoms, success rate of manual reduction of incarcerated inguinal hernia, subsequent treatment, operative findings, and outcome of strangulated cases in pediatric patients. Materials and Methods: This is a retrospective study involving 56 children under 15 years of age with a diagnosis of complicated inguinal hernia managed between January 2009 and December 2018 at a tertiary care hospital in Nigeria. Demographic characteristics, clinical presentations, management, and outcome were retrieved. Data were analyzed using SPSS software version 22 (IBM Corp., NY, USA). The results were presented as frequencies and percentages. Categorical variables were analyzed using Chi-square test. P &lt; 0.05 was deemed statistically significant. Results: The age of patients ranged between 8 days and 14 years, with a median of 2 months; 79% were infants. Males outnumbered females by a ratio of 27:1, and the rate of incarceration was 5.0%. Majority (89.3%) had no previous hospital visits. Those who had successful manual reduction was 80%. Time of presentation was a statistically significant factor for successful reduction, P &lt; 0.05. One patient experienced en masse reduction, and there was no mortality. Conclusion: Majority of those with incarcerated inguinal hernias were infants, and manual reduction was associated with early presentation.

A 9-year experience study of single-port micro-laparoscopic repair of pediatric inguinal hernia using a simple needle

PurposeAs laparoscopic techniques and equipments improve, laparoscopic inguinal hernia repair has been gaining popularity. The objective of the study was to summarize 9 years of experience using a single-port micro-laparoscopic approach to repair pediatric inguinal hernias with a simple hernia needle.Methods1880 children with inguinal hernias were enrolled using micro-laparoscopic surgery between June 2009 and 2018. All patients underwent high ligation surgery using a single-port micro-laparoscopic technique. The clinical data were retrospectively analyzed.ResultsAll micro-laparoscopic surgeries were successfully performed in the 1880 patients, who ranged in age from 2 months to 14 years (3.66 ± 2.96 years) including 1622 males and 258 females. Among them, 1299 cases were unilateral hernias and 581 cases were bilateral hernias. The average operating time was 12.5 ± 3.5 min for a unilateral hernia and 20.5 ± 4.5 min for bilateral hernias. All patients were discharged 1–2 days after surgery, and the average length of their hospital stay was 2–4 days. Complications of knot reaction and pneumoscrotum occurred in 5 cases (0.27%) and 54 cases (2.87%), respectively, but these cases were properly managed, with no major impact on the operational outcomes. All patients were followed up for 3–65 months; there were 13 recurrent cases (0.69%).ConclusionsSingle-port micro-laparoscopic herniorrhaphy in children using a simple hernia needle is a reliable and minimally invasive procedure.

Our Laparoscopic Surgical Technique and Experience in Treating Pediatric Inguinal Hernia Over the Past Decade.

Background:Over the past decade, laparoscopic hernia repair was the most performed operation in our department. Equally, it compromises 15% of all pediatric operations performed. We aim, in this study, to review all the cases performed and extrapolate important information like reoccurrences, the incidence of metachronous inguinal hernia, complications amongst other information.Material and Methods:All patients under the age of 18 whom underwent elective laparoscopic hernia repair between 03/01/2007 till the 18/05/2016 were included in our study. We recorded important clinical features and studied their post-operative follow up. Equally reoccurrences, the incidence of metachronous inguinal hernia, complications and other parameters were recorded and studied.Results:A total of 916 patients were operated on during the defined study period. There was a 0.17% reoccurrence rate and a 0.46% incidence of metachronous inguinal hernia. Equally a contralateral patent processus vaginalis was diagnosed and closed in 17.10%. There were no postoperative complications and we had a 0% postoperative hydrocele rate.Conclusion:Laparoscopic hernia repair is safe and carries all the benefits of minimally invasive surgery. We recommend that it is offered to patients and would like to refute previously claimed reports that it carries a higher reoccurrence rate or takes a long time to perform. Our reoccurrence rate of 0.17% is actually lower than many published reoccurrence rates after open repair.

The Ideal Candidate for Subcutaneous Endoscopically Assisted Ligation (SEAL) of the Internal Ring for Pediatric Inguinal Hernia Repair

Subcutaneous endoscopically assisted ligation (SEAL) technique is an effective and minimally invasive approach for indirect inguinal hernia repair in children. Not all patients are candidates for SEAL because of technical limitations. We hypothesized that preoperatively assessed patient-level factors may predict technical feasibility of SEAL repair. We performed a retrospective review of all patients who underwent indirect inguinal hernia repair between June 2012 and December 2014. All patients younger than two years and any patient older than two years who had a concomitant umbilical hernia were considered candidates for diagnostic laparoscopy with SEAL repair. We compared patients who had SEAL repair with those who had diagnostic laparoscopy with conversion to open repair. Univariate statistics was performed using the chi-squared and Student's t test. One hundred forty-one patients underwent diagnostic laparoscopy with intent to perform a SEAL repair. Seventeen patients were lost to follow-up. Of the remaining 124 patients, 66 had SEAL repairs, 35 had open repairs, and 23 had a SEAL repair with contralateral open repair. Patient age, BMI, gender, history of prematurity, and history of incarcerated hernia were similar between the SEAL and open groups. Sixty-two per cent of hernias were able to be repaired with SEAL technique. Hernia recurrence was seen in 3 of 123 total SEAL repairs and in 1 of 74 open repairs. The recurrence rate for SEAL repairs (2.4%) was not significantly different from the recurrence rate for open repairs (1.4%). No preoperative patient-level factors predicted technical inability to perform a successful SEAL repair. In this series, the recurrence risk of SEAL compared with open repair was low and not statistically significant. For practitioners with minimally invasive experience, SEAL should be considered a safe and successful option for inguinal hernia repair in pediatric patients undergoing routine diagnostic laparoscopy.

Accidental bladder injury during elective inguinal hernia repair: a preventable complication with high morbidity.

Bladder injury (BI) represents a rare complication of inguinal hernia surgery. Protrusions of the urinary bladder through the deep inguinal ring ("bladder ears") have been reported with an incidence of 9% in infants younger than 6months of age and may be misinterpreted as the hernia sac. This literature review was designed to determine incidence and outcomes of bladder injuries during pediatric inguinal hernia repair. A literature review of the literature (1967-2017) was performed using the keywords "bladder ears", "inguinal hernia", "iatrogenic bladder injury" and "bladder hernia". Publications were reviewed for epidemiology, presentation and extent of injury, treatment and outcome. Thirteen articles reporting on 30 cases of BI during inguinal hernia repair from 1967 to 2017 were included (19 boys, 2 girls, 9 unknown). Median age at herniotomy was 10.5months (1month-6years). Out of 30 children, 14 (47%) experienced mild complications. Sixteen patients (53%) had severe complications after initial surgery and needed revisional surgery. Complications were noticed up to 4years after the initial surgery. In 9 (56%) of the 16 severe cases, major damage to the bladder wall and impairment of bladder capacity occurred. In seven patients (44%), secondary closure was successful. In ten patients (63%), the bladder was partially resected, and in one child (6%), the entire bladder was removed. The degree of accidental BI during inguinal hernia repair was severe in in the majority of reported cases in the literature. Surgeons should be aware of the high prevalence of "bladder ears" in infants to prevent injury to the urinary tract.