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Pediatric Surgical Procedures – An Updated Guide – Volume I
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the vas and testicular vessels, divided, and followed proximally to the internal inguinal ring, where it is ligated with a doubly absorbable suture. The distal sac should
be dilated extensively, but it is unnecessary to remove it. If a hydrocele is present,
it is evacuated; however, it is not necessary to perform an excision of the hydrocele
sac. In cases of large sacs, they may be everted behind the cord, which is commonly
called the bottle procedure. The entire sac can be resected following high ligation in
the event of a blind-ending sac. It is uncommon for minors to require formal floor
restoration. Inversion ligation is comparatively straightforward to perform after the
placement of a proximal purse-string suture in the presence of a sliding hernia [9].
As we have mentioned, there are many differences in the approach to hernia
surgery between females and males. In females, it tends to be simpler than in males
due to the absence of the necessity of preserving a spermatic cord. The process starts
with the identification of the hernia sac and its inspection for contents.
The sac frequently houses the ovary, tube, or mesosalpinx. If the sac is vacant, it is
divided between clamps. Following cauterization of the wound’s margins, the distal
capsule is reinserted into the cut. The proximal sac is dissected out to the internal
ring, contorted, and doubly ligated. The transversalis fascia is then approximated to
the shelving edge of the inguinal ligament, and the internal ring is closed using one or
two sutures. The inguinal ligament is then closed in the standard manner. According
to a study, it is imperative to routinely expose the sac prior to twisting and ligation, as up to 40% of indirect inguinal hernias in females have a sliding component
(
Figure ). In the event that the fallopian tube is not readily visible, certain surgeons
will apply traction to the round ligament to identify the tube prior to ligating the sac.
Additionally, refrain from performing the Bastianelli maneuver, which involves the
routine attachment of the sac and the round ligament to the conjoint tendon to restore
the uterus’s normal support [34].
No attempt should be made to dissect the fallopian tube from the sac if it is identified as a sliding hernia in the sac wall. Rather, it employs a purse-string closure to close
the sac above the fallopian tube, reduce the sac into the internal ring, and close the
internal ring with one or two sutures, a procedure referred to as the Bevan repair [7, 46].
Open unilateral hernia correction is the standard of care for adolescents with a unilateral inguinal hernia; contralateral exploration protocols are unnecessary [46, 47].
Contralateral exploration is associated with risks, and not all patent processus
vaginalis develop into clinically pertinent hernias; this may be considered an unnecessary surgical risk [46, 48].
Figure 4.
Incarcerated hernia in a female child.
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. Laparoscopic repair
Since 1975, minimally invasive surgery has been shown to be feasible and safe for
pediatric patients. Laparoscopic surgery was first used to treat a small bowel obstruction [49]. El-Gohary in 1997 described laparoscopic repair of inguinal hernias in pediatric patients [49]. Operation was initially performed only in female patients because
the safety of the vas and vessels is of concern in males. Monteput and Esposito [50]
were involved in the repair of inguinal hernias in male children and were the first
to use laparoscopy using an intracorporeal purse-string suture to close the inguinal
ring. According to a literature review by Smith et al., Schier described intracorporeal
Z-suture closure first in girls only (1998) [33] and then in boys (2000) [51, 52]. Chan
and Tam described intracorporeal hydrodissection as a technique to prevent damage
to the vas and vessels in males [53]. Also, other modifications of the intracorporeal
method include the incision of the peritoneum [54], using it to cover the patent
processus vaginalis [55], or making an excision of the sac laparoscopically [56].
Prasad et al. [57] described the use of extracorporeal suturing. After that, there
have been multiple changes in medical practice to make the extracorporeal suture
more accessible from a technical point of view [58]. Hydrodissection has used both
intracorporeally and extracorporeally [59]. The latest improvements are related to the
reduction in the number of incisions required to make the surgery [60]. Diagnostic
laparoscopy has been used to confirm the hernia’s presence in order to make a smaller
incision for an otherwise relatively standard open repair [61].
The laparoscopic method includes several benefits. A cohort study where children
underwent laparoscopic herniotomy reported similar pain scores, complications, and
recurrence as open herniotomy. Similarly, they reported excellent results in the same
age group, with a mean age of 19.1months in phase I and a mean age of 17.6months
in phase II. In literature reports, recurrence rates are similar between the two studied
laparoscopic methods [62].
Literature recommends that the patient be positioned in the Trendelenburg position. The monitor is situated at the foot of the operating table, while the surgeon and
assistant are situated at the top of the table. CO2 is insufflated into the abdomen at a
pressure of 5–8mmHg through an umbilical incision, and a 3-mm trocar is inserted.
Two 2-mm apertures are positioned superiorly and medially to the anterior apical iliac
spine in telescopic vision [63, 64].
The internal aperture of the hernia is verified by examining the contralateral side. Up
to 40% of cases exhibit a contralateral patent processus vaginalis. The decision to close
these during the same operation is a matter of debate, as not all of them will develop
into a clinical hernia in the future, potentially exposing certain patients to superfluous
operative risk. However, the majority of the parents ask for its repair [63, 64].
. Intraperitoneal purse-string closure
The secure application of a purse-string suture is facilitated by the subperitoneal
injection of normal saline for boys, which separates the vas deferens and testicular
vessels from the peritoneum. A laparoscopic grasper is used to lift the peritoneum
that covers the testicular vessels and vas deferens [28].
The peritoneum is elevated away from the vas deferens and testicular vessels by
injecting 2mL of normal saline and using either normal saline or local anesthestic to
conduct hydrodissection. A needle is introduced, and the space beneath the distended
peritoneum is entered under visual observation. To guarantee the appropriate
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isolation of the vas and testicular vessels from the peritoneum, saline is injected
laterally around the ring and subsequently medially. The injector is subsequently
withdrawn. Certain surgeons also employ a diathermy hook to diathermize or incise
the collar of the hernia sac. As the literature says, this has been demonstrated in a
rabbit model to produce an even more lasting repair [28].
Coran et al. [28] affirm that the technique should be implemented with a nonabsorbable monofilament suture that is introduced into the peritoneal cavity by passing it through the abdominal wall. The purse-string suture is initiated at the 2 o’clock
position of the internal hernia opening. As they say, the needle should be observed
to traverse the subperitoneal space, free of the vas and testicular vessels, with each
successive bite of the peritoneum around the hernia ring.
. Burnia technique
Authors such as Mendoza et al. [65] emphasize that the burnia technique has
become a very recommendable surgical treatment for inguinal hernias in girls, as its
advantages offer better postoperative results, the chance to revise the contralateral
inguinal canal, and also better esthetic results. Nevertheless, it is necessary for further
investigation to establish it as a gold standard of surgery, as it requires extensive
experience to be conducted efficiently.
According to Mendoza et al. [65], “the Burnia technique is performed with the
patient in the supine position and using laparoscopic materials such as a 3.5 and
5.3mm 30° lens, as well as laparoscopic forceps and monopolar energy.” The Hasson
technique is used to make a 0.5-cm incision in the umbilical region. It starts with a
disposable 5-mm trocar that is used to insert the laparoscopic vision lens. CO2 is used
to produce pneumoperitoneum, with different pressures correlated with the age of
the patient but usually between 10 and 12mmHg. It is important to make a panning of
the abdominal cavity and inguinal region to identify where the lesion is located and to
assess the contralateral side. Next, a second cut is made on the right flank for a second
3-mm trocar. Then, a work clamp with a 3-mm monopolar connector is introduced to
find vaginal peritoneum with the lesion. Then, the hernial sac is pulled away from the
peritoneal wall with the Babcock fórceps and without content. When the procedure is
finally done, the pneumoperitoneum is evacuated, and the trocars are removed under
direct vision [65].
. Alternative technique
On the other hand, the flip-flap technique is an alternative approach that entails
an incision in the peritoneum that is 1cm lateral to the internal inguinal ring. In the
manner of a trap door, the hernia orifice is concealed by raising a flap of peritoneum
and flipping it across to the internal inguinal ring. A continuous suture should be
used to secure the closure of the hernia ring between the free border of the peritoneal membrane and the contiguous hernia ring. The closure of extensive hernias is
achieved without tension through the use of a peritoneal membrane [21, 28].
. Extraperitoneal closure
The extracorporeal approach is about placing a suture circumferentially around
the internal ring and tying the knot using percutaneous techniques. There have been
many variations of this approach. Ostlie and Ponsky reviewed the literature and
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stated that there was insufficient evidence to support one approach over another [9].
An umbilical incision is made to introduce a 3-mm telescope into the peritoneal cavity,
and pneumoperitoneum is established. Under telescopic guidance, a stab incision is
made in the lower abdomen, midway between the umbilicus and suprapubic tubercle,
to introduce a 2- or 3-mm grasper. Position this port on the ipsilateral side of the
hernia; however, the authors consistently position it in the left lower abdomen [28].
Next, it is required to make a small stab wound just at the 12 o’clock position of the
internal inguinal ring lateral to the internal inguinal ring. Utilize a 25-gauge finder
needle to perform a hydrodissection by first performing it laterally and then medially
through the stab incision. Inject either normal saline or a local anesthetic to separate
the peritoneum from the vas deferens and testicular vessels. A deeper incision is made
in the preperitoneal compartment [28].
To assist in the creation of scar tissue and increase the durability of the repair
performance, thermal energy is applied through a stab incision at this point around
the internal ring [28].
Place a spinal needle through the stab incision at the 12 o’clock position and pass
laterally around the internal ring in the hydrodissection plane, over the cord structures. Use a Maryland dissector to assist in lifting the peritoneum off the cord structures while passing the spinal needle. After the spinal needle has passed over the cord
structures, it should be pushed through the peritoneum into the abdominal cavity.
The looped monofilament suture is then pushed out partially from the needle, and the
needle is removed, leaving the suture in place [21, 28].
To access the prior hook entrance point in the peritoneum, it is recommended to
re-insert the hook into the anteromedial portion of the preperitoneal region. Dissect
the medial semicircle of the internal inguinal ring in the same way as previously.
Back into the peritoneal cavity, the hook goes. A suture is passed through the hook’s
eye. The suture will fully wrap the internal inguinal ring when the hook is withdrawn. By compressing the distal hernia sac, the pneumoperitoneum may be freed.
Reintroducing pneumoperitoneum ensures that the hernia closure is airtight when the
circumferential suture is knotted extracorporeally [21, 28].
. Robotic repair
Additional problems, such as a lack of instrument diversity and an adequate size
for younger patients, have slowed the introduction of robotic surgery into pediatric
operations. Some have voiced worries about patient safety, citing factors such as the
lengthened operation time and limited access for anesthetic patients caused by the
size of the robotic system. Robotic surgery has seen a significant increase in its use on
juvenile patients during the last decade, despite these restrictions. Robotic pediatric
surgical treatments, according to Cundy et al. [66], saw a case volume rise of over
100% between April 2011 and March 2021. The biggest increases were seen in urologic
and foregut operations.
The size of the surgical robot and its equipment is the main concern highlighted
by Denning et al. [67] in 2020 about robotic surgical technology in pediatric surgery.
Compared to the 3-mm instruments often used in conventional laparoscopic operations, the only two sizes of robotic tools that have been authorized for use in pediatrics,
8mm and 5mm, are much bigger. Additionally, a 5-mm robotic endoscope was
removed due to poor usage; therefore, the only accessible diameters are 12.0mm and
8.5mm. The intercostal gap of a youngster weighing 5kg or less would be too vast for
the 8.5-mm scope, even if it could be used with larger children. So, according to the da
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Vinci surgical platform maker, you should space the ports 8cm apart. Due to their tiny
stature, infants and toddlers would have a hard time covering this distance [39, 68].
. Recurrent inguinal hernias
Recurrent inguinal hernias rarely represent an emergency. This allows the medical professional to assess the best options for treatment. Nevertheless, it is one of the
most important concerns after a primary repair. Fortunately, the rise of new techniques and the increasing scientific advances in the matter have allowed the medical
community to choose between several approaches that include the open and laparoscopy approach [3, 10, 69–71].
Literature shows that open repair is the recommended option in cases where the
recurrent hernia is concomitant to incarceration, ascended testis, sliding hernia
containing the ovary, previous open intra-abdominal surgery, or if the peritoneum at
the inner orifice is scarred. However, according to evidence, laparoscopy has gained in
popularity for its low rates of complications related to infection. Not only represents
a non-invasive procedure but also has improved the incidence of pain, hematomas,
and time in the hospital. In our opinion, despite its benefits, it should be taken into
account the expertise of the surgeon and the specific case of the patient [72].
. Hernia repair with mesh
In their study, Reistrup et al. said there is a lack of long-term follow-up data
and data comparing mesh vs. non-mesh repairs in teenagers. In 2024, researchers
looked at data from 4000 groin hernia surgeries and found that open procedures
were more common and mesh was seldom employed in teenage cases. There were
zero high-quality randomized controlled trials, and the majority of the research
was small retrospective cohort studies with no prospective data. Both the mesh and
non-mesh procedures had minimal recurrence occurrences (<2%), according to a
meta-analysis. All surgical procedures seem to have a tolerable risk of chronic pain,
which ranges from 0–11%. A case-based survey demonstrated that for surgeons,
surgical approaches to teenagers differed depending on whether they mostly dealt
with adult or pediatric patients. It seems that there is a lack of consistency in the
treatment of adolescents, depending on the surgeon who is treating them. Pediatric
physicians used high ligation, whereas adult surgeons employed either mesh or
non-mesh procedures [73].
Due to the high recurrence incidence and inadequacy of standard hernia sac
ligation surgery, Chen et al. [74] suggested a biological patch for youngsters aged
13–18. Furthermore, the posterior wall of the inguinal canal should also be repaired
and strengthened in order to prevent a recurrence. At present, it is not advocated
for children with hernia, from 13 to 18years old, to be treated with a non-biological
synthetic patch (polypropylene) because they are still in the growth and development
stage [14]. For children and adolescents, their muscle and fascia tissue will gradually
become stronger as the growth and development stage. The absorbable biological
materials can rely on their own characteristics to repair defects in the early stages and
generate new tissue plates through tissue replacement to prevent the recurrence of
hernias in the long term.
Lichtenstein, in 1984, proposed the open “tension-free” mesh repair technique, which is still considered the method of choice for primary inguinal hernia.
Lichtenstein hernioplasty with the biological patch was used to treat inguinal hernias
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in children and adolescents between 13 and 18years old. This procedure involves placing a biological patch in front of the transversalis fascia to strengthen the back wall of
the inguinal canal [19].
. Special cases
.. Amyand’s hernia
The standard therapy for Amyand’s hernia is appendectomy with primary hernia
repair. If perforation or pelvic abscess is suspected, it is preferred to perform a lower
midline laparotomy approach as it is easier to manage. In cases of gangrenous acute
appendicitis, Solecki et al. suggest a midline inferior laparotomy and Shouldice’s
herniorrhaphy. This is also supported by Salemis et al., who reported that during a
laparoscopic approach on an indirect inguinal hernia, they discovered a gangrenous
perforated appendix with peritonitis, requiring a midline laparotomy [19].
Lately, a wider range of approaches has started to show up in the published
works. Vermillion et al. documented the first laparoscopic appendectomy in a case of
Amyand’s hernia with appendicitis [19]. It has recently come to light that laparoscopic
surgery is becoming more common, although it is needed choose an open repair
approach if complications arise.
In addition, according to Ivashchuk G et al., a growing number of patients are having their Amyand’s hernias repaired with extraperitoneal management. Additionally,
Saggar et al. described the comprehensive extraperitoneal therapy that included the
use of synthetic mesh for hernioplasty and appendectomy [19].
.. Littré’s hernia
Littré’s hernia management is surgical, with reduction of the hernia, repair of the
hernia defect, and resection of the diverticulum [75].
Management of asymptomatic and incidentally found diverticulum prophylactic
resection may be pursued. Generally, resection is the management of diverticulum
encountered during a routine repair of hernia, though the reasoning behind this is not
elucidated [76].
.. Direct inguinal hernias
In children, direct inguinal hernias are rare, even in older teenagers. Direct and
femoral hernias are often unrecognized preoperatively. Direct inguinal hernias can
be managed in children and adolescents with an open McVay repair (approximation
of the transversalis aponeurotic arch and internal oblique aponeurosis to the anterior
ileopubic tract and shelving edge of the inguinal ligament), a Bassini approach, or
with mesh [9].
Laparoscopic repair is also an attractive option for a direct inguinal hernia.
However, the laparoscopic technique is different for a direct inguinal hernia repair
as there is a large lipoma adherent to the hernia sac with a direct hernia. It is important to perform laparoscopically the reduction of the lipoma into the abdominal
cavity, followed by excision using a hook cautery. Excision of the lipoma is one
of the key points of direct repair, closure of the defect using several interrupted
nonabsorbable sutures, and use of the vesical ligament to reinforce the closure of
the defect without tension [9].
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It is rare to find in children combinations of direct and indirect hernias, the
so-called pantaloon hernias, or even combinations of indirect, direct and femoral
hernias, and the best way to identify them is the laparoscopic approach [9].
.. Femoral hernias
In the infant population, femoral hernias are rare, representing just about
0.2% of all hernias. In fact, prior to surgery, most of them were not suspected.
It is even common that, due to the difficulty in identifying them with an open
approach, they are sometimes misdiagnosed as indirect inguinal hernias. On the
other hand, they are evenly distributed between males and females, with a mean
diagnostic age of around 5–7years. The presence of a mass under the inguinal
ligament and medial to the femoral vessels should serve as an alarm to the surgeon about this potential. Femoral hernias that affect both legs occur in 10–20%
of instances. However, the laparoscopic surgery reduced the risk of reoperation
compared to the open repair, according to a Danish dataset that analyzed 3970
adult femoral hernia procedures. Additionally, low recurrence rates have been
reported in small pediatric studies. Laparoscopic surgery is not the only option;
open mesh or mesh plug repairs, as well as Cooper ligament repairs, are other
viable choices [9].
. Ventriculoperitoneal shunts or peritoneal dialysis
According to Hammer et al. [77], procedures that introduce fluid into the
peritoneal cavity may produce a hernia or hydrocele in patients with a patent processus vaginalis. Excess fluid in the peritoneal cavity is a major risk factor for the
development of inguinal hernias as well. However, it is unclear whether increased
intra-abdominal pressure or the fluid itself is what causes hernia. There could be a
role for abnormal neuromuscular function as well. According to a study by Moazam
and colleagues that looked at 134 patients who underwent ventriculoperitoneal shunt
surgeries, 19.5% of meningomyelocele patients and 47% of intraventricular hemorrhage patients had inguinal hernias. According to Grosfeld and Cooney, inguinal
hernias occurred 14% of the time after ventriculoperitoneal shunt implantation,
with 20% experiencing incarceration and 16% experiencing a recurrence of the
hernia [19]. The study concluded that infants undergoing ventriculoperitoneal shunts
should be closely monitored for the development of a clinical inguinal hernia due to
the increased risk of incarceration, surgery should be performed immediately upon
diagnosis of a hernia [4], and in patients with a unilateral hernia, the contralateral
side should be investigated [5].
Patients on long-term ambulatory peritoneal dialysis have a documented risk
of inguinal hernia ranging from 7 to 15%. When inserting the peritoneal dialysis
catheter, it is advised to do an intraoperative herniography. After 15minutes of being
in a head-up posture, the patient receives water-soluble contrast via the catheter. A
repair is necessary if a patent processus vaginalis is detected. Another option is to
directly see the internal ring via laparoscopy while inserting the catheter, especially if
the procedure is carried out laparoscopically. Both open and laparoscopic methods of
repair may thereafter be used [77].
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. Inherited disorders of connective tissue
Patients with inherited disorders such as Hunter-Hurler, Ehlers-Danlos, and
Marfan síndromes present higher rates of inguinal hernia incidence and recurrence.
However, this can be prevented by repairing the floor of the inguinal canal with
ligation of the sac. In research conducted by Coran and Eraklis, it was found that 36%
of the 50 patients with Hunter-Hurler syndrome developed an inguinal hernia. When
the high ligation was performed alone, the recurrence rate was as high as 56%. Several
studies recommend this technique be combined with floor repair with mesh [9].
. Cystic fibrosis
The prevalence of cystic fibrosis has risen by 6%, while inguinal hernia cases have
surged by 15%. The occurrence of missing vas deferens in the overall population ranges
from 0.5 to 1%, as indicated by research on vasectomy. Irregularities in the vas deferens
in individuals with cystic fibrosis, which can vary from blockages to total absence, are
always found and typically affect both sides. Consequently, if the vas deferens cannot
be identified, it should prompt an assessment for cystic fibrosis. The absence of the
vas deferens is linked to kidney malformation in individuals without cystic fibrosis;
therefore, it is advised to assess the upper urinary system in these cases [9].
. Intersex
On very rare occasions, a phenotypic female may be genetically male suffering
from androgen insensitivity syndrome or a genuine hermaphrodite. The presence of
testicular tissue, sometimes called “the ovotestis,” should prompt a thorough evaluation of any ovary found inside a female patient’s hernia sac. Males who suffer from
androgen insensitivity syndrome have smaller testis but no uterus or fallopian tubes.
Upon inspection of the gonad, an asymmetric ovotestis is seen, and hermaphrodites
may have a fallopian tube inside the hernia sac. It is not necessary to remove an aberrant gonad in either case. It involves removing a little wedge-shaped piece from each
pole, replacing the gonad, and fixing the hernia.
. Splenogonadal Fusión
The fusion of splenic tissue with a healthy testis is known as splenotesticular
fusion. The typical preoperative diagnosis for a scrotal mass presentation is a testicular tumor. Having an orchidectomy is not required; a frozen section during surgery
can give the diagnosis and enable the testis to be saved. The fusion of the spleen and
ovaries may also be observed. The fusion of the spleen and gonads can also manifest
as a testis that has not descended or a mass within the abdomen. The use of laparoscopy is beneficial for both diagnosing and treating this ailment [9].
. Adrenal rests
Ectopic adrenal tissue is not rare and has been found in 10 of 385 operations
for inguinal hernia (2.6%), an incidental finding in each case, appearing as a small
mass of yellowish tissue in the apex of the hernia sac. In another series, however, the
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incidence was 0.2% in 1077 sacs analyzed. The adrenal tissue at this site is likely the
result of the attachment of developing adrenal cells to the testis before descent from
the retroperitoneum to the scrotum during fetal development [9].
. Postoperative care
Except for newborns who need extended time to be monitored, the majority of
patients may usually be sent home within 2 hours following surgical repair. However,
while newborns have no activity limitations, older kids should wait to ride bikes or
engage in other strenuous physical activities until the discomfort disappears [21].
. Postoperative complications
.. Scrotal swelling
In children, scrotal edema is the most prevalent consequence that might occur
after inguinal hernia surgery. Scrotal edema is a concern for caretakers and may vary
in severity from patient to patient, making it a potential consequence. The scrotal
edema might be due to the scrotal dissections done during surgery or to the loose
areolar tissues of the scrotum. Scrotal hematoma, which occurs when blood collects
in the scrotal sacs, may be caused by insufficient hemostasis after surgery [78]. Repair
of a subsequent scrotal hydrocele or aspiration may be required in rare cases, although
this usually goes away on its own. After the distal sac is removed, a scrotal hematoma
may form [9].
.. Infection
An infrequent complication is a major wound infection; hernia surgery is a clean
surgery. It is more common in cases of strangulated inguinal hernia. Obesity patients,
prolonged duration of operation, and use of local anesthesia are the most common
contributing factors to wound infection [79]. Treatment is carried out with broadspectrum antibiotics.
.. Recurrence
Incarcerated inguinal hernias that require emergency repair are more likely to
recur. The inguinal region may be anatomically deformed, there may be tissue edema,
the sac may be friable or not be completely dissected, the ligature may slide at the
neck of the sac, or the sac may not be ligated high enough at the internal ring [9,78].
Due to the potential increased technical difficulties and danger of harm to cord
structures in the scarred, previously treated inguinal canal, several authors advise
a laparoscopic method for treating recurrent hernias. A laparoscopic technique for
recurrence surgery shortens the operating time and has low problems in several minor
series [80].
.. Testicular atrophy
Even though testicular vessels are especially susceptible to surgical damage in
newborns, very few cases of testicular atrophy after standard hernia repairs have been
reported. Fischer et al. [9] reported that testicular atrophy occurs 1% of the time.
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According to some research, an irreducible hernia may have obstructed blood flow to
the testis, leading to testicular atrophy. Children with undescended testicles or who
are less than 2years old have a greater chance of developing testicular atrophy [81].
.. Iatrogenic ascending testis
A rare complication in children is postoperative ascending testis. A study, including 3776 pediatric inguinal hernia and hydrocele cases, showed an incidence of
ascending testis around <1% after an open operation. Therefore, the ascending testis
after laparoscopic herniotomy is considered to be less than those statistics after open
repair because the laparoscopic approach does not destroy the structure of the inguinal canal [82]. Secondary orchidopexy is required to correct this problem [9].
.. Injury to the vas deferens
Vas deferens iatrogenic lesions are severe complications of inguinal canal surgery. There are a lot of procedures that involve the vas deferens in pediatric surgical
practices. Understanding the consequences of regular inguinal exploration on the
inguinal canal’s architecture is crucial. The majority of pediatric operations involve
inguinal disease, which necessitates the involuntary manipulation of the vas deferens
and other arteries. Sometimes it is impossible to avoid accidentally crushing inguinal
contents, and the outcomes are completely unforeseeable. While iatrogenic separation is more dangerous, any disruption to the vas’s continuity might have functional
consequences for a long time [83]. The avoidance of iatrogenic damage requires a
precise surgical approach that includes early diagnosis and minimum manipulation
of the spermatic and vas deferens arteries. Due to the modest exterior and luminal
dimensions (1.0mm and 0.19mm.), a repair is technically more difficult if the vas is
damaged before mid-puberty. However, current developments in microsurgery still
make a repair viable. Microsurgical vasovasostomy is the preferred method of treatment for any damage that is discovered after mid-puberty [84].
.. Intestinal injury
The incidence of intestinal infarction is remarkably low with incarcerated hernias.
In the report by Rowe and Clatworthy of 351 patients between 1960 and 1965, the
incidence of intestinal resection with incarcerated hernias was 1.4%. A review of the
hernias series published since 1978 shows no resections in 221 patients with incarcerated hernias [9].
.. Loss of abdominal domain
The division of abdominal contents between the hernia and the remaining abdominopelvic cavity is sometimes referred to as loss of domain (LOD). Physical problems
might develop after hernia repairs if the hernia has a wide lumen of dilation (LOD),
meaning that much of the abdominal viscera is outside the abdominal compartment.
When intra-abdominal pressure rises, the diaphragm becomes pushed up, which may
lead to pneumonia and respiratory failure. The laparotomy incision is more likely to
be torn apart by the increased strain caused by rising abdominal pressure; this may
lead to wound problems and hernia recurrence. Postoperative recurrence is a major
concern; therefore, researchers are trying to identify pre-operative variables that can
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