Journal of Surgical Technique and Case Report
Journal of Surgical Technique and Case Report


 
  Table of Contents 
REVIEW ARTICLE
Year : 2012  |  Volume : 4  |  Issue : 1  |  Page : 1-5  

Surgical techniques of laparoscopic inguinal hernia repair in childhood: A critical appraisal


Department of Surgery, Paediatric Surgery Unit, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Web Publication5-Sep-2012

Correspondence Address:
Christopher S Lukong
Department of Surgery, Paediatric Surgery Unit, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2006-8808.100343

Rights and Permissions
   Abstract 

Laparoscopic inguinal hernia repair started over two decades ago. It has been gaining ground as a mode of treatment for inguinal hernia in children. Several surgical techniques have emerged since its inception. The aim of this article is to review the role of laparoscopy in inguinal hernia repair in children, the various emerging laparoscopic surgical techniques, and their current trend in pediatric surgical practice. In this study, extensive review and analysis of recent articles on laparoscopic inguinal hernia repair in children revealed that laparoscopy plays a great role in the treatment of inguinal hernia in children. There were several emerging laparoscopic techniques, with trends toward extracorporeal suturing and knotting technique and single-port access technique as well. The recent advance is toward the use of tissue adhesives in laparoscopic inguinal hernia repair in children.

Keywords: Children, hernia, inguinal, laparoscopic, repair, technique


How to cite this article:
Lukong CS. Surgical techniques of laparoscopic inguinal hernia repair in childhood: A critical appraisal. J Surg Tech Case Report 2012;4:1-5

How to cite this URL:
Lukong CS. Surgical techniques of laparoscopic inguinal hernia repair in childhood: A critical appraisal. J Surg Tech Case Report [serial online] 2012 [cited 2018 Dec 16];4:1-5. Available from: http://www.jstcr.org/text.asp?2012/4/1/1/100343


   Introduction Top


Inguinal hernia is a common condition in children. The treatment for this condition is high ligation of patent processus vaginalis at the level of the internal inguinal ring. This can be achieved either by conventional open method or by laparoscopic technique. [1]

There have been conflicting reports regarding the place of laparoscopy in the treatment of inguinal hernia in children. [2] At the moment, laparoscopic inguinal hernia repair is not only possible in children, but also is gaining ground as a safe, feasible, and popular method. [3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] There are, however, several reports comparing the conventional open method and laparoscopic inguinal hernia repair in children, but the current trend is toward laparoscopic method. [16],[17],[18],[19],[20]

With increasing interest in laparoscopic inguinal hernia repair, several treatment techniques have developed over the past two decades, aimed at improving the outcome. [21] The various techniques differ in their approach to the inguinal internal ring, suturing and knotting techniques, number of ports used in the procedure, endoscopic instruments used, mode of dissection of the hernia sac, and gender of the patient as well. The emerging techniques show a tendency for simple extracorporeal suturing and knotting technique, and diminished use of endoscopic ports and instruments.

The aim of this article is to review the role of laparoscopy in inguinal hernia repair in children, the various emerging laparoscopic surgical techniques, and their current trend in pediatric surgical practice.


   Materials and Methods Top


Literature search was performed using search engines like Google, PubMed, SpringerLink, and journals. Search for English language articles on laparoscopic inguinal hernia in children was done. Citations found in selected articles were screened and used for further references. The articles were selected based on appropriateness to the subject matter, year of publication (articles beyond 1990 were excluded), operative procedure, and institutions where the studies were conducted.

The various techniques were evaluated based: approach to the inguinal internal ring (intraperitoneal or extraperitoneal), suturing and knotting techniques (intracorporeal or extracorporeal), number of ports used (three, two, or one), instruments used, and outcome of procedure (safety, feasibility, and reproducibility).


   Results Top


There have been a lot of publications on laparoscopic inguinal hernia repair over the past two decades, based on PubMed citations on this topic. Laparoscopic inguinal hernia repair is currently employed in developed countries and developing countries as well.

The papers reviewed show that laparoscopy has a role in the treatment of inguinal hernia in children. The advantages, disadvantages, and limitations of this procedure are well highlighted in the articles.

The various laparoscopic surgical techniques for inguinal hernia repair in children cited in the review include: intracorporeal or extracorporeal, three- or single-port procedure, sac inversion and ligation in female children, resection and no ligation technique, flip-flap technique, and finally use of tissue adhesives - a current concept.


   Discussion Top


Laparoscopic inguinal hernia repair in children started over two decades ago. Initially it was doubtful whether this mode of treatment could be employed in children. This controversy lingered on until several reports established that this procedure was feasible and safe in children. [3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] Then came the controversy between laparoscopic and conventional open surgery for inguinal hernia repair in children. [16],[17],[18],[19],[20]

Role of laparoscopy

The above controversies have been overtaken by events. This review establishes the fact that more and more laparoscopic inguinal hernia repairs are being carried out in children with satisfactory outcome. [22],[23],[24] Laparoscopic inguinal hernia repair has an established role in the management of this condition in children in trained hands. Indeed, it is fast becoming the gold standard for the treatment of inguinal hernia in children. The laparoscopic technique has the advantage that it is simple, feasible, and safe. Also, the contralateral internal inguinal ring and other hernia sites such as femoral, obturator, or internal hernia can be diagnosed and treated at same sitting and other occult pathologies may be diagnosed. The risk of injury to the vas deferens and cord structures in this procedure is lesser when compared to the conventional open technique. [16],[17],[18],[19] The general advantages of laparoscopic technique such as cosmesis, low wound infection, less pain, and short hospital stay, all apply here. The disadvantages of laparoscopic technique in inguinal hernia repair in children are: it is expensive, longer duration of surgery, higher recurrence rates, and longer learning curve when compared to the conventional open method. The technique is highly limited if there is no training, and there is lack of expertise and equipment.

The issue of injury to the vas deferens and affectation of testicular vascular supply following laparoscopic surgery has been addressed. Indeed, studies by Schier and Parelkar et al. have shown that laparoscopic inguinal hernia repair in children does not affect testicular perfusion or growth. [6],[13] None of the studies reviewed recorded any incidence of injury to the vas deferens.

Laparoscopic techniques

With increasing interest, there has been a proliferation of various techniques in the laparoscopic repair of inguinal hernia in children. This proliferation has been orchestrated by refinements in methods of ligation of the patent processus vaginalis at the internal inguinal ring in order to improve results and the outcome of treatment. The various techniques are: extracorporeal or intracorporeal suturing and knotting, three- or single-port procedure, sac inversion and ligation technique in girls, flip-flap technique, and use of tissue adhesives. Some studies have been highlighted in order compare the various techniques vis-à-vis the authors and their complication rates [Table 1], [Table 2] and [Table 3].
Table 1: Comparison between extracorporeal and intracorporeal techniques

Click here to view
Table 2: Various techniques by different authors and recurrence rates

Click here to view
Table 3: Comparison between three and single port (Bharathi et al. J Laparoendosc Adv Surg Tech A, 2008)[40]

Click here to view


Extracorporeal suturing and knotting technique

The review shows that extracorporeal technique is currently being adopted by many pediatric surgeons. [25],[26],[27],[28],[29] The two-port technique using nonabsorbable suture material is employed. The trend is shifting toward this technique because it is simple, safe, feasible, and reproducible. This method particularly has low recurrence rates (0-2.0%), and more importantly, knotting does not require any special skill because it is done externally in the subcutaneous tissue in the conventional manner [Table 1]. The low recurrence rate in this technique is attributed to the fact that in this procedure the sac is wholly ligated without leaving skip portions. The skip portions, especially at the medial aspect of internal inguinal ring, account for some of the recurrences in some reports. [22],[28] The limitation of this technique is that special needles and introducers are required. In the review, spinal needle, special 19-guage needle, hook, and host of other instruments are currently being used with good outcome. [28]

Intracorporeal suturing and knotting technique

This was the initial method adopted at the inception of laparoscopic inguinal hernia repair in children. The technique employs three ports and uses nonabsorbable suture materials. In this method, intraperitoneal knotting is performed to close the internal inguinal ring. The closure is achieved by applying a suturing in purse-string fashion and knotting tight the internal inguinal ring. Sometimes interrupted suturing is done to close the ring. [10] This method has a high recurrence rate (0-5.7%) and is not as simple and easy as the extracorporeal technique. Here, good intracorporeal laparoscopic knotting skill is required [Table 1].

Inversion and ligation technique

This method of laparoscopic inguinal repair is widely used in female children. This is a modification of the intracorporeal technique, using three ports and nonabsorbable sutures. It is thought that inversion and ligation of sac at the internal inguinal ring would reduce the risk of recurrence (0.8-2.5%). [30],[31],[32] The problems faced in the intracorporeal technique may also apply here. In a similar manner, the selective sac extraction method for inguinal hernia repair in children by minimally invasive procedure has been described with satisfactory surgical and cosmetic outcome by Ikeda et al.[33] In the sac extraction method, the sac is extracted and ligated openly. In the inversion and ligation technique, the sac is isolated, inverted, and ligated laparoscopically.

Resection and ligation technique

This is another modification of the intracorporeal technique, with three ports and nonabsorbable sutures employed. In this technique, the hernia sac is resected and closed with a purse-string suture at the level of the internal inguinal ring. Becmeur et al. recorded no recurrence with this method. [34] This was done in an attempt to reduce the recurrence.

Resection and no ligation technique

Here, the hernia sac is resected at the level of the internal inguinal and allowed to close spontaneously. This novel technique has been reported in literature with preliminary results showing satisfactory outcome and no recurrence. [35] The method uses three ports and no sutures are employed.

Flip-flap technique

In this procedure, a flip-flap is raised in the internal inguinal ring and used to close the defect. This is a three-port technique that uses absorbable sutures. Yip et al. did not record any recurrence with this technique. [36] Satisfactory results have been noticed by Hassan et al. in a comparative study of this flip-flap technique with the conventional open technique. [37]

Three-port or single-port technique

The pioneer procedures for inguinal hernia repair in children by laparoscopy used the three-port method. Recently, with refinements in technology, the single procedure is currently attracting attention. In their experience with modified single-port laparoscopic procedures in children, Rothenberg et al. found very encouraging outcome. [38] This report corroborates with a study by Chang on technical refinements in single-port laparoscopic surgery of inguinal hernia in infants and children. [39] In a comparison study by Bharathi et al., single-port technique was preferred to the three port due to better outcome. [40] The technical difficulties encountered with the single port are a major limitation [Table 3].

Use of tissue adhesives

Initial animal experimental studies showed that tissue adhesives could be used in tissue approximation. [41] Further, experimental animal models have continued to establish the role of tissue adhesives in inguinal hernia repair. [42],[43] Cusheiri in a study had earlier published an article forecasting the promising role of tissue adhesives in endosurgery. [44] Today tissue adhesive is being employed in a host of pediatric endoscopic surgeries, including inguinal hernia repair. [45]

Current trend

This review shows preference for extracorporeal technique because it is simple, safe, reproducible, and has low recurrent rates. [21] The other trend is toward the single-port technique because it results in virtually scarless abdomen as the surgical incision is hidden within the umbilicus. [38],[39]


   Conclusion Top


Laparoscopy plays a great role in the treatment of inguinal hernia in children. There are several emerging laparoscopic techniques in the repair of inguinal hernia in children, geared toward improving results and outcome. The current trend is toward extracorporeal suturing and knotting technique and single-port access technique as well. The future or recent advancement is the use of tissue adhesives in laparoscopic inguinal hernia repair in children.


   Acknowledgment Top


I wish to express my profound gratitude to Prof. R. K. Mishra, whose teaching, inspiration, and advice enabled me to publish this article.

 
   References Top

1.Brandt ML. Pediatrichernias. SurgClin North Am 2008;88:27-43.  Back to cited text no. 1
[PUBMED]    
2.Rosenberg J. Pediatric inguinal hernia repair: A critical appraisal. Hernia2008;12:113-5.  Back to cited text no. 2
    
3.Tan HL. Laparoscopic repair of inguinal hernias in children. J PediatrSurg 2001;36:833.  Back to cited text no. 3
[PUBMED]    
4.Holcomb GW 3 rd . Diagnostic laparoscopy for congenital inguinal hernia. SeminLaparoscSurg 1998;5:55-9.  Back to cited text no. 4
    
5.Schier F, Montupet P, Esposito C. Laparoscopic inguinal herniorrhaphy in children: A three-center experience with 933 repairs. J PediatrSurg 2002;37:395-7.  Back to cited text no. 5
[PUBMED]    
6.Schier F. Laparoscopic inguinal hernia repair- a prospective series of 542 children. J PediatrSurg 2006;41:1081-4.  Back to cited text no. 6
[PUBMED]    
7.Kaya M, Huckstedt T, Schier F. Laparoscopic approach to incarcerated inguinal hernia in children. J PediatricSurg 2006;41:567-9.  Back to cited text no. 7
    
8.Chinnaswamy P, Malladi V, Jani KV, Parthasarthi K, Shetty RA, Kavalakat AJ, et al. Laparoscopic inguinal hernia repair in children. JSLS 2005;9:393-8.  Back to cited text no. 8
    
9.Chan KL, Pam PK. A safe laparoscopic technique for the repair of inguinal hernias in boys. J Am CollSurg 2003;196:987-9.  Back to cited text no. 9
    
10.López Diaz M, Cano Novillo I, GarcíaVázquez A,CabezalíBarbancho D, Tejedor Sánchez R, PortelaCasalod E, et al. Laparoscopic inguinal herniorrhaphy in children. First results. Cir Pediatr 2007;20:220-2.  Back to cited text no. 10
    
11.Arbell D, Orkin B, Udassin R. Laparoscopic inguinal hernia repair in infants. Harefuah 2007;146:745-6.  Back to cited text no. 11
    
12.Turial S, Enders J, Krause K, Schier F. Laparoscopic inguinal herniorrhaphy in babies weighing 5Kg or less. SurgEndosc 2011;25:72-8.  Back to cited text no. 12
    
13.Parelkar SV, Oak S, Gupta R, Sanghvi B, Shimoga PH, Kaltari D, et al. Laparoscopic inguinal hernia repair in a pediatric age group-experience with 437 children. J pediatrSurg 2010;45:789-92.  Back to cited text no. 13
    
14.Esposito C, Montinaro L, Alicchio F, Savanelli A, Armenise T, Settimi A. Laparoscopic treatment of inguinal hernia in the first year of life. J LaparoendoscAdvSurg Tech A 2010;20:473-6.  Back to cited text no. 14
    
15.Oak SN, Parelkar SV, K R, Pathak R, Viswanath N, Akhtar T, et al. Large inguinal hernia in infants: Is laparoscopic repair the answer? J Laparoendosc Adv Surg Tech A 2007;17:1148.  Back to cited text no. 15
    
16.SarangaBharathi R, Arora M, Baskaran V. Pediatric inguinal hernia: Laparoscopicversus open surgery. JSLS 2008;12:277-81.  Back to cited text no. 16
    
17.Niyogi A, Tahim AS, Sherwood WJ, De Caluwe D, Madden NP, Abel RM, et al. A comparative study examining open inguinal herniotomy with or without hernioscopy to laparoscopic inguinal hernia repair in a paediatric population.PediatrSurgInt 2010;20:387-92.  Back to cited text no. 17
    
18.Kuhry E, Van Veen RN, Langeveld HR, Steyerberg EW, Jeckel J, Bonjer H. Open or total extraperitoneal inguinal hernia repair? A systemic review.SurgEndosc 2007;21:161-6.  Back to cited text no. 18
    
19.Nah SA, Glacomello L, Eaton S, de Coppi P, Curry JI, Drake DP, et al. Surgical repair of incarcerated inguinal hernia in children. Laparoscopic or open.Eur J PediatrSurg 2011;2:8-11.  Back to cited text no. 19
    
20.Endo M, Watanabe T, Nakano M, Yoshida F,Ukiyama E. Laparoscopic completely extraperitoneal repair of inguinal hernia in children; a single-institute experience with 1257 repairs compared with cutdownherniotomy. SurgEndosc 2009;23:1706-12.  Back to cited text no. 20
    
21.SarangaBharathi R, Arora M, Baskaran V. Minimal access surgery of pediatric hernia: A review. SurgEndosc 2008;22:1751-62.  Back to cited text no. 21
    
22.Giseke S, Glass M, Tapadar P, Matthyssens L, Philippe P. A true laparoscopic herniotomy in children.Evaluation of long term outcome. J laparoendoscAdvSurg Tech A 2010;20:191-4.  Back to cited text no. 22
    
23.Ozgediz D, Roayaie K, Lee H, Nobuhara KK, Farmer DL, Bratton B, et al. Subcutaneous endoscopically assisted ligation(SEAL) of the internal ring for repair of inguinal hernia in children: Report of a new technique and early results. SurgEndosc 2007;21:1327-31.  Back to cited text no. 23
    
24.Zakehara H, Yakabe S, Kameola K. Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: Clinical outcome of 972 repairs done in 3 pediatric surgical institutions. J PediatrSurg 2006;41:1999-2003.  Back to cited text no. 24
    
25.Kellnar S. Percutaneous laparoscopic hernia repair in children. ZentralblChir 2009;134:542-4.  Back to cited text no. 25
    
26.Dutta S, Albanese C. Transcutaneous laparoscopic hernia repair in children: A prospective review of 275 hernia repair with minimium 2 year follow up. SurgEndosc 2009;23:103-7.  Back to cited text no. 26
    
27.Uchida H, Kawashima H, Goto C, Sato K, Yoshida M, Takazawa S, et al. Inguinal hernia repair in children using single-incision laparoscopic-assisted percutaneous extraperitoneal closure. J PediatrSurg 2010;45:2386-9.  Back to cited text no. 27
    
28.Shalaby R, Ismail M, Dorgham A, Hefny K, Alsaied G, Gabr K, et al. Laparoscopic hernia repair in infancy and childhood: Evaluation of 2 different techniques. J PediatrSurg 2010;45:2210-6.  Back to cited text no. 28
    
29.Patkowski D, Czernik J, Chrzan R, Jawoski W, Apoznanski W. Percutaneous internal ring suturing: A minimally invasive technique for repair of inguinal hernia in children. J LaparoendoscAdvSurg Tech A 2006;16:513-7.  Back to cited text no. 29
    
30.Lipskar AM, Soffer SZ, Glick RD, Rosen NG, Levitt MA, Hong AR. Laparoscopic inguinal hernia inversion and ligation in female children: A review of 173 consecutive cases at a single institution. JPediatrSurg 2010;45:1370-4.  Back to cited text no. 30
    
31.Guner YS, Emami CN, Chokshi NK, Wang K, Shin CE. Inversion hernoiotomy: A laparoscopic technique for female inguinal hernia repair. J LaparoendoscAdvSurg Tech A 2010;20:481-4.  Back to cited text no. 31
    
32.Zallen G, Glick PL. Laparoscopic inversion and ligation inguinal hernia repair in girls. J LaparoendoscAdvSurg Tech A 2007;17:143-5.  Back to cited text no. 32
    
33.Ikeda H, Hatanaka M, Suzuki M, Fuji J, Takara K, Ishimara Y. Selective sac extraction method: Another minimally invasive procedure for inguinal hernia repair in children: A technical innovation with satisfactory surgical and cosmetic outcome. J PediatrSurg 2009;44:1666-71.  Back to cited text no. 33
    
34.Becmeur F, Philippe P, Lemandat-Schultz A,Moog R, Grandadam S, Lieber A, et al. A continuous series of 96 laparoscopic inguinal hernia repair in children by a new technique. SurgEndosc 2004;18:1738-41.  Back to cited text no. 34
    
35.Riquelme M, Aranda A, Riquelme-QM. Laparoscopic pediatric inguinal hernia repair: No ligation, just resection. J LaparoendoscAdvSurg Tech A 2010;20:77-80.  Back to cited text no. 35
    
36.Yip KF, Tam PK, Li MK. Laparoscopic flip-flap hernioplasty: An innovative technique for pediatric hernia surgery. SurgEndosc 2004;18:1126-9.  Back to cited text no. 36
    
37.Hassan ME, Mustafawi AR. Laparoscopic flip-flap technique versus conventional inguinal hernia repair in children. JSLS 2007;11:90-3.  Back to cited text no. 37
    
38.Rothenberg SS, Shipman K, Yoder S. Experience with modified single port laparoscopic procedures in children. J LaparoendoscAdvSurg Tech A 2009;19:695-8.  Back to cited text no. 38
    
39.Chang YT. Technical refinements in single port laparoscopic surgery of inguinal hernia in infants and children.DiagTherEndosc 2010;2010:392847.  Back to cited text no. 39
    
40.Bharathi RS, Dabas AK, Arora M, Baskaran V. Laparoscopic ligationof internal ring- three port versus single port technique. Are working ports necessary? J LaparoendoscAdvSurg Tech A 2008;18:891-4.  Back to cited text no. 40
    
41.Olguner M, Aktuq T, Akqur FM, Pabuccuoglu U. Experimental study investigating the feasibility of new method for laparoscopic indirect hernia repair. J InvestSurg 1997;10:189-92.  Back to cited text no. 41
    
42.Kato Y, Yamataka A, Miyano G, Tei E, Koga H,Lane GJ, et al.Tissue adhesives for repairing inguinal hernia: A preliminary study. J LaparoendoscAdv Tech A 2005;15:424-8.  Back to cited text no. 42
    
43.Turial S, Kreutz M, Hausser S, Enders J, Schier F. CD rats as an animal model in the experimental study of laparoscopic hernia repair. Eur J PediatrSurg 2010;20:330-3.  Back to cited text no. 43
    
44.Cushieri A. Tissue adhesives in endosurgery. SeminLaparoscSurg 2001;8:63-8.  Back to cited text no. 44
    
45.Esposito C, Damiano K, Settimi A, De Marco M, MaglioP, Centonze A. Experience with use of tissue adhesives in pediatric endoscopic surgery. SurgEndosc 2004;18:290-2.  Back to cited text no. 45
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


This article has been cited by
1 Laparoscopic Totally Extraperitoneal Repair in a Pediatric Patient for Recurrent Inguinal Hernia
Steven J. Schuetz,Brian P. Blackwood,Ezra N. Teitelbaum,Alexander P. Nagle,Catherine J. Hunter
Journal of Laparoendoscopic & Advanced Surgical Techniques Part B, Videoscopy. 2016;
[Pubmed] | [DOI]
2 Pseudo-recurrence following female laparoscopic inguinal hernia repair in children
Akila Ramaraj,Jason C. Fisher
Journal of Pediatric Surgery Case Reports. 2016;
[Pubmed] | [DOI]
3 Two Ports Laparoscopic Inguinal Hernia Repair in Children
Medhat M. Ibrahim
Minimally Invasive Surgery. 2015; 2015: 1
[Pubmed] | [DOI]
4 “Double N”: Evolution of the Surgical Technique for Laparoscopic Herniorrhaphy After 10-Year Experience in a Single Center
Michele Libri,Francesca Destro,Noemi Cantone,Stefania Pavia,Mario Lima
Journal of Laparoendoscopic & Advanced Surgical Techniques. 2015; 25(8): 684
[Pubmed] | [DOI]
5 Laparoscopic percutaneous inguinal hernia repair in children: Review of technique and comparison with open surgery
Matthew D. Timberlake,Katherine W. Herbst,Sara Rasmussen,Sean T. Corbett
Journal of Pediatric Urology. 2015; 11(5): 262.e1
[Pubmed] | [DOI]
6 Laparoscopic single instrument closure of inguinal hernia in female children: A novel technique
Ahmed AbdElgaffar Helal
Journal of Pediatric Surgery. 2015; 50(9): 1613
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusion
   Acknowledgment
    References
    Article Tables

 Article Access Statistics
    Viewed3131    
    Printed196    
    Emailed1    
    PDF Downloaded263    
    Comments [Add]    
    Cited by others 6    

Recommend this journal