Laparoscopic inguinal hernia repair by modified peritoneal leaflet closure: Description and initial results in children. Issue 3 (June 2018)

• Record Type: Journal Article
• Authors: Van Batavia, Jason P.; Tong, Carmen; Chu, David I.; Kawal, Trudy; Srinivasan, Arun K.
• Is Part Of: Journal of pediatric urology. Volume 14:Issue 3(2018)
• Page Start: 272.e1
• Page End: 272.e6
• Publication Date: 2018-06
• Subjects: Laparoscopy -- Inguinal hernia repair -- Herniorrhaphy -- Surgical technique; Pediatric urology -- Periodicals; Urologic Diseases -- Periodicals; Urogenital Diseases -- Periodicals; Urologic Surgical Procedures -- Periodicals; Child; Infant; Urologie pédiatrique -- Périodiques; Appareil urinaire -- Maladies -- Périodiques; Pédiatrie; Urologie; Pediatric urology; Périodique électronique (Descripteur de forme); Ressource Internet (Descripteur de forme); Electronic journals; Periodicals; Electronic journals; 618.926
• DOI: 10.1016/j.jpurol.2018.02.015
• Languages: English
• ISSNs: 1477-5131

Abstract

Summary: Introduction: Inguinal hernias are common in infants and children. While the gold standard for hernia repair in the pediatric period has been via an open inguinal incision with dissection and high ligation of the hernia sac, over the past two decades laparoscopic herniorrhaphy has increased in popularity. The advantages of laparoscopy include decreased post-operative pain, improved cosmetic results, ability to easily assess the contralateral side for an open internal inguinal ring, and decreased risk of metachronous hernias. Herein, we describe a modified laparoscopic herniorrhaphy using a peritoneal leaflet closure and report our operative experience with intermediate-term results. Methods: We retrospectively reviewed our IRB-approved registry for all children who underwent initial laparoscopic herniorrhaphy at our tertiary care center over a 2.5-year period. All surgeries were performed by a single surgeon using a technique we have termed the peritoneal leaflet closure. This technique involves incising the peritoneum circumferentially around the open internal ring and developing peritoneal leaflets which are then closed together over the ring with a running non-absorbable barbed stitch (Figure ). Intraoperative findings and complications, operative times, and post-operative complications were reviewed for all children. Results: A total of 50 initial laparoscopic hernia repairs (4 bilateral, 42 unilateral) were performed in 46 children (43 boys, 3 girls) at a median age of 5.9 years (range 0.5–16.7). Median operative time was 73 min (range 48–138) for unilateral and 106 min (range 104–135) for bilateral herniorrhaphy. No patient had an intraoperative complication. Two children (4%) had contralateral open rings discovered at time of surgery and underwent unplanned bilateral laparoscopic hernia repair. All patients went home on the same day as the procedure and three children (6%) had minor post-operative complaints (umbilical bulge, thigh pain, and urine holding) that all self-resolved. Thirty-nine children had follow-up data available. Intermediate-term complications occurred in two children (5%): one boy developed a contralateral hydrocele (despite a closed ring at surgery) and one boy had a hernia recurrence that required open repair. Overall, operative success with the modified peritoneal leaflet closure technique was therefore 97% (38 of 39 children with follow-up). All 37 boys who followed up had bilateral descended testes of normal size and consistency. Conclusions: Laparoscopic herniorrhaphy using a peritoneal leaflet closure technique is safe and effective when used in infants and children to close an indirect hernia (i.e. patent processus vaginalis). No intraoperative complications occurred in this cohort and success rate was 97%. Figure Intraoperative images of modified peritoneal leaflet closure technique in a right-sided inguinal hernia. (A) An incision is made circumferentially in the peri-orificial peritoneum just proximal to the internal inguinal ring (dashed white line). Care must be taken to identify and preserve the vas deferens (yellow arrow) and testicular vessels (red arrow) during this step. (B) Image immediately after dissection and development of the peritoneal leaflets. (C) The peritoneal leaflets are then closed together over the internal inguinal ring with a running, non-absorbable barbed suture.