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INTRODUCTION:
Inguinal hernias are common in infants and children with an incidence between 1-4% and open inguinal repair is the gold standard of treatment. With advancing minimal invasive techniques, laparoscopic herniorrhaphy has increased in popularity since it was first described in 1993. 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 flap closure and report our operative experience with outcomes.
METHODS:
We retrospectively reviewed our IRB-approved registry for all children who underwent initial laparoscopic herniorrhaphy at our tertiary care center between 4/2013 and 1/2016. All surgeries were performed by a single surgeon using a technique we have termed the primary peritoneal flap repair. Briefly, 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 barbed stitch. 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 minutes (range 48-138) for unilateral and 106 minutes (range 104-135) for bilateral herniorrhaphy. No patient had an intraoperative complication. Four boys (8%) required hydrocelectomy at the time of laparoscopic repair and one boy required conversion to open repair for inguinal floor repair. Two children (4%) had contralateral open rings with scrotal insufflation discovered at time of surgery and underwent unplanned bilateral laparoscopic hernia repair. All patients went home the same day as the procedure and three children (6%) had minor post-operative complaints (umbilical bulge, thigh pain, and urine holding) that all resolved spontaneously. Thirty-nine children had follow up data available at a median of 3 months (range=1-27). Complications occurred in two children (4%): one boy (2%) developed a contralateral hydrocele (despite a closed ring at surgery) and one boy (2%) had an indirect hernia secondary to inguinal floor weakness that required modified Bassini’s repair . All 37 boys who followed up had bilateral descended testes of normal size and consistency.
CONCLUSIONS:
Laparoscopic herniorrhaphy using a primary peritoneal flap repair technique is safe and effective when used in infants and children to close a patent processus vaginalis. No intraoperative complications occurred in this cohort and success rate was 98%. This technique could be particularly useful in older children, children with bilateral hernias and recurrent hernias.