Elsevier

Journal of Pediatric Surgery

Volume 42, Issue 12, December 2007, Pages 1993-1997
Journal of Pediatric Surgery

Towards a near-zero recurrence rate in laparoscopic inguinal hernia repair for pediatric patients of all ages

https://doi.org/10.1016/j.jpedsurg.2007.08.014Get rights and content

Abstract

Background/Purpose

The recurrence rate in laparoscopic inguinal hernia (LIH) repair remains high. The aim of this study was to assess whether the introduction of technical improvements, including (1) decreasing tension on the purse-string knot when closing the internal hernia opening by injecting normal saline extraperitoneally, (2) using an airtight knot, and (3) stress-testing the airtightness of the knot by increasing intraperitoneal gas pressure, could eliminate recurrence in LIH repair in pediatric patients of all ages.

Methods

A retrospective review was performed of the prospectively collected data of 451 LIH repairs in 314 children of various ages in our institution from September 2002 to September 2006. The technical improvements mentioned above to prevent recurrence were introduced in the second half of the series of operations (tensionless repair [TL]). The data on both groups of operations were then compared.

Results

A total of 225 hernias were repaired in the first group (164 patients), compared with 226 in the TL group (150 patients). The differences between the ratio of boys to girls (129:35 vs 112:38) and the mean ages (50.84 ± 48.15 vs 45.59 ± 47.95 m) in the 2 groups were not statistically significant. The recurrence rate in the TL group was much lower than in the first group (0.4% vs 4.88%, P = .003). There was no postoperative testicular atrophy in either group of patients.

Conclusion

It is possible to achieve a near-zero recurrence rate in laparoscopic hernia repair in pediatric patients of all ages.

Section snippets

Operation in the first half of the series

The technique has been described elsewhere [6], [7]. Female patients were given general endotracheal anesthesia and then placed in the Trendelenberg position. A 5-mm port was inserted through the umbilicus. A pneumoperitoneal pressure of 8–10 mm Hg was created. The internal opening of the hernia was confirmed, and the contralateral side was also inspected. Two more 3-mm ports were placed medial to the anterior superior iliac spine into the peritoneal cavity under telescopic vision. A 4/0

Results

The first group, in which 225 hernias were repaired, contained 164 patients. The TL group, in which 226 hernias were repaired, contained 150 patients (Table 5). The differences in the sex ratio of boys to girls (129:25 vs 112:38) and in the mean ages (50.84 ± 48.15 vs 45.59 ± 47.95 m) between the 2 groups were not statistically significant.

Because there were more younger patients in the TL group (37/150 vs 12/164; P = .0256), more bilateral inguinal hernias were discovered and repaired during

Discussion

There is no muscular weakness in pediatric inguinal hernia. It becomes clear to many pediatric surgeons that there is no need to have muscular strengthening procedures in hernia repair in this group of patients [8].

In a large series of 6361 child inguinal hernias over a 35-year period treated with open herniotomy, the recurrence rate was found to be 1.2% [9]. It should be possible using laparoscopic repair to avoid some of the causes of recurrence in open herniotomy. These include failure to

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    All studies (intra-corporeal repair in n = 738 children and extra-corporeal repair in n = 2942 children) assessed ipsilateral recurrence rate (Table 4) which varied from 0–4.9% with the highest recurrence reported by Chan et al. (n = 314 children). They reported a recurrence rate of 4.9% in the group that used an intra-corporeal technique with injection of normal saline extra-peritoneally (n = 164 children) compared to 0.4% in the intervention group that used an intra-corporeal technique with injection of normal saline extra-peritoneally before tying an airtight knot [12]. Five studies (n = 664 children; one study comparing intra-corporeal closure and four comparing extra-corporeal closure) reported zero recurrent hernias during a follow-up period varying from 3 months until 1 year.

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Presented at the 40th annual meeting of the Pacific Association of Pediatric Surgeons, Queenstown, New Zealand, April 15-19, 2007.

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