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The Role of Laparoscopy in the Repair of Pediatric Inguinal Hernias
81
the structure is unable to be repaired then the two ends should be tagged with non-absorbable
monofilament for later identification and repair. Since most pediatric surgeons perform
thousands of inguinal hernia repairs throughout their career, it stands to reason that with the
open approach iatrogenic injuries are statistically likely to occur more than once in a career.
Several animal studies have looked at excessive and aggressive handling of the vas and
merely stretching the structure can have long-term implications for inadvertent crush injury
and fibrosis. Only grasping with fingers seems to have minimal detrimental effect on this
tenuous structure when evaluated after manipulation [Shandling and Janik, 1981; Ceylan et
al., 2003] Similarly, injury to the vas may result in obstruction and subsequent destruction of
the blood-testes barrier resulting in activation of autoantibodies to spermatozoa and
subsequent infertility [Coran et al., 2012]. Although the incidence of infertility after inguinal
hernia repair has not been well defined, the data does suggest an association exists and this
may be a reason for infertility in men. [Friberg and Fritjofsson, 1979; Parkhouse and Hendry,
1991]
Testicular and Gynecologic Injury
Complete devascularization of a testicle is a rare event but transient ischemia occurs
relatively frequently during emergency exploration for incarcerated viscera, with a reported
rate of 2.6%-5% of patients [Coran et al., 2012]. Compression of the testicular vessels often
leads to ischemia, which can be appreciated at exploration but should not lead to orchiectomy
unless the testicle is grossly necrotic. The reported incidence of testicular atrophy ranges from
0%-19% detected on follow-up examination [Coran et al., 2012]. Most often, the testicle will
recover and achieve normal size and function postoperatively.
Ovarian and fallopian tube incarceration is more likely to lead to detrimental ischemia
due to their tendency to twist within the hernia sac. Up to 1/3 of herniated ovaries that cannot
be easily reduced have been reported to result in strangulation and organ loss [Boley et al.,
1991; Pampal and Atac, 2013]. Subsequent scarring of the fallopian tube or oophorectomy of
a necrotic ovary contributes to decreased fertility in these select patients. Prompt surgery for
irreducible hernias in females is recommended to minimize ovarian loss.
Recurrence
The reported recurrence rate for indirect inguinal hernias is less than 1%; but increases to
15% in premature infants, 20% in incarceration and as high as 50% in patients with
connective tissue disorders and other comorbidities [Lloyd, 2003; Ein et al., 2006; Coran et
al., 2012]. In addition, these numbers may be grossly understated because there is a paucity of
literature with prolonged follow up into adulthood [Zendejas et al., 2010]. Risk factors for
recurrence include conditions which predispose to increased intraabdominal pressure (chronic
cough, ventriculoperitoneal shunt, peritoneal dialysis), and technical shortcomings like
tearing the sac, not ligating the sac high at the internal ring and slipped ligature [Coran et al.,
2012]. Premature infants are at a particular risk due to the frailty of the hernia sac and the
subsequent difficultly in maintaining its integrity during dissection [Baird et al., 2011].
Damian Maxwell and Robert Baird
82
Incarcerated hernias pose a similar risk due to inflammation of the sac and spermatic cord
so we therefore recommend delaying the repair, in those patients that can be reduced
nonoperatively, for 24 to 48 hours to allow for the inflammation to subside. Injury to the floor
of the inguinal canal can present later as a direct inguinal hernia and may be underreported as
a recurrence. Direct inguinal and femoral hernias, although rare, may have initially been
misdiagnosed as indirect hernias or missed at the time of initial operation. Many if not all of
these pitfalls may be mitigated with laparoscopy, although literature regarding its efficacy and
safety continues to accrue.
THE LAPAROSCOPIC OPTION
Laparoscopic inguinal hernia repair has become commonplace in adult patients, with
several approaches described. Advantages of the laparoscopic repair include earlier discharge
from hospital, earlier return to work, improvement on objective pain scores and simultaneous
bilateral hernia repair, all of which have been supported by robust meta-analyses [Memon et
al., 2003; Wake et al., 2005]. These potential advantages need to be tempered by the well-
documented increased cost and longer operative times associated with the laparoscopic
approach. In addition, since the pathophysiology of pediatric hernias and adult hernias differ
(patent processus vaginalis versus a dilated deep ring) [Gray and Skandalakis, 1972] the
techniques of repair should necessarily differ accordingly. The chief distinction is the use of
exogenous material to reinforce adult repairs (both open and laparoscopic), whereas foreign
material is relatively contra-indicated in the growing tissues of pediatric patients, and results
in an unacceptable rate of infection and mesh migration. Many adult surgeons now use a total
extraperitoneal approach (TEP) for the repair of inguinal hernias although a clear superiority
in outcomes when compared to transabdominal preperitoneal (TAPP) approaches has not
been definitively demonstrated [McCormack et al., 2005; Gass et al., 2012].
For many pediatric surgeons, laparoscopy for inguinal hernia appeared more costly and
challenging to perform successfully without a clinically significant cosmetic or other
postoperative benefit. The purported advantages of laparoscopy appeared limited in children
when compared to the small incision, minimal dissection and acceptable post-operative pain
associated with a successful “open” herniorrhaphy. In addition, recovery from surgery is
extremely prompt in pediatric patients, thereby minimizing any potential improvement with
the laparoscopic approach. Furthermore, pediatric patients rarely concern themselves with
‘return-to-work’, a data-point frequently evaluated and championed by adult laparoscopic
enthusiasts. On the other hand, many of the previously unrecognized benefits to laparoscopy
are becoming increasingly evident.
One of the chief advantages of laparoscopy for pediatric hernia repair is the ability to
identify a contralateral patent processus vaginalis (CPPV) through direct visualization during
ipsilateral repair. The LOOC (laparoscopy of the other canal) technique was initially
described by placing a 70-degree lens through the ipsilateral hernia sac to inspect the other
side. This was validated by Valusek et al. [2006] and shown to be more effective than clinical
exam or exam under anaesthesia in identifying CPPV. An earlier meta-analysis by Miltenburg
et al. [1998] was found the LOOC to be both safe and effective. On the other hand, the
angulation of the contralateral patent processus can limit the utility and reliability of this
The Role of Laparoscopy in the Repair of Pediatric Inguinal Hernias
83
approach. It is described less frequently in the more recent literature given the widespread
adoption of the transumbilical approach, which provides an unobstructed view and enables
immediate laparoscopic repair. Hall et al. [2012] evaluated the age-related probability of
having a CPPV through logistic regression analysis and illustrated that the risk is not
insignificant and varies inversely based on gestational age. Based on this data, laparoscopic
inguinal hernia repair in infants less than a year of age (for which CPPV is the highest risk)
affords the greatest advantage in closing the ipsilateral hernia with concomitant evaluation
and closure of the contralateral patent processus if present. When parents were faced with the
question of an open inguinal approach for the repair of ipsilateral inguinal hernia versus
laparoscopic hernia repair plus evaluation for CPPV, the vast majority chose laparoscopy in
the hope of avoiding another anesthetic for their child [Esposito, 2012].
The first laparoscopic series in girls described an intraperitoneal, transumbilical approach
of inverting and twisting the hernia sac then performing a high ligation with an endoloop
(Ethicon, Inc., Somerville, NJ, USA) [El-Gohary et al., 2003]. This technique is reserved for
girls, and several other transperitoneal approaches have evolved but due to the higher
recurrence rates have mostly been abandoned. Laparoscopic Z-stitches were utilized but
resulted in recurrence rates of 2.7%, 3-fold higher than the traditional open approach
[Montupet and Esposito, 1999; Gorsler and Schier, 2003].
When other groups began experimenting with an extraperitoneal approach to placing the
purse string suture, the recurrence rate fell precipitously to 0.8% [Lee and Liang, 2002]. The
SEAL technique (subcutaneous endoscopic assisted ligation of the hernia sac) allows for the
extracorporeal encircling of the hernia sac with avoidance of the cord structures and
subsequent high ligation [Harrison et al., 2005; Ozgediz et al., 2007]. In 2009, a large series
reported a recurrence rate of 0.2% in short- and long-term follow up extending to 11 years,
using the extraperitoneal technique. This recurrence rate is certainly on par with
contemporary data for the open hernia repair method [Endo et al., 2009].
Incarceration of an inguinal hernia poses unique challenges. Encountering an edematous
hernia sac and inflamed tissue planes are pitfalls that even experienced surgeons struggle to
overcome. The laparoscopic view allows the surgeon to evaluate the herniated viscera for
viability, as well as the contralateral inguinal region for an unsuspected bilateral hernia, while
sidestepping the challenging environment of the inguinal canal and its adversarial contents.
When comparing laparoscopy versus open repair for incarcerated inguinal hernias (IIH),
laparoscopy seems to offer advantages to the open technique with a lower incidence of
complications [Nah, et al., 2011].
Technique
The technique employed by the senior author of this chapter is based largely on the
description by Dutta and Albanese [2009]. It involves placing the patient under general
anesthesia and in a slight Trendelenberg position with the surgeon standing on the patient’s
left and the assistant to the patient’s right (Figure 2). A Veress needle, in a STEP® (Covidien,
Inc., Mansfield, MA, USA) sheath, is then inserted through an umbilical incision and
pneumoperitoneum is established. We usually start with a pressure of 8mmHg and a flow of 2
L/minute, adjusting for patient age as needed to enable optimal visualization. At this point the
diagnosis is established by confirming the presence of a patent processus vaginalis (Figure 3).
Damian Maxwell and Robert Baird
84
Once the operative field is established, a stab incision is created in the left lower quadrant
with a #11 scalpel blade to admit a 3mm instrument and create a “zone of injury”, anterior or
anterolateral and away from the vas and vessels, by cauterizing the peritoneum of the internal
inguinal ring (Figure 4). The addition of this thermal trauma to the peritoneum has been
shown to improve closure rates in an animal model of indirect inguinal hernia [Blatnik et al.,
2012]. A 25 gauge needle is then used to locate at 12 0’clock the internal ring percutaneously
through the abdominal wall prior to making a tiny skin incision with a #11 scalpel blade at
this location. Several laparoscopists employ non-absorbable monofilamant to circumnavigate
the hernia defect, although we favor a braided suture primarily for its handling characteristics.
The percutaneous passage of a 2.0 Ethibond® [Ethicon, Inc., Somerville, NJ, USA] suture on
a curved tapered needle is performed under laparoscopic guidance with manipulation of the
ring by the 3mm instrument to assist in avoiding the vas and vessels while circumnavigating
the internal ring in an extraperitoneal plane (Figure 5). The needle is then retrieved on the
opposite side of the ring extracorporally and, without removing the hub of the needle, its
direction is reversed and passed through the subcutaneous tissue back out the initial #11 blade
incision in the abdominal wall. This completes the encircling of the internal ring and
effectively creates a high ligation of the hernia sac (Figure 6). We then lift and tie the suture
under laparoscopic visualization of the internal ring to observe tight approximation and
ensure that the suture hasn’t pulled through and that there is an air tight seal. The knot is then
buried in the subcutaneous tissue and a Steri-strip® (3-M, Inc., St. Paul, MN, USA) is placed
on that incision as well as on the 3mm stab incision; and the umbilicus is closed in the
standard fashion. [Dutta and Albanese, 2009]
Source: Reprinted with permission from Dutta, S., Albanese, C.(2009). Transcutaneous laparoscopic
hernia repair in children: a prospective review of 275 hernia repairs with minimum 2-year follow-
up. Surg Endosc.23:103–107.
Figure 2. Diagram of patient and surgeon positioning.
The Role of Laparoscopy in the Repair of Pediatric Inguinal Hernias
85
Figure 3. Laparoscopic view of right inguinal hernia in a male child.
Figure 4. Laparoscopic view of right inguinal hernia in a male child after deliberate electrocautery to
the antero-lateral surface of the peritoneum.
Damian Maxwell and Robert Baird
86
Figure 5. Laparoscopic view of right inguinal hernia in a male child with suture passed in an
extraperitoneal plane, anterior to the vas deferens and vessels.
The senior author of this chapter has completed 113 laparoscopic inguinal hernia repairs
between 2010 and 2012, with a mean of 8 months follow-up. There have been three known
recurrences, two of which occurred in neonatal cases. In addition, a 1-year-old patient
returned with a small umbilical hernia that is being managed conservatively. No other
complications have been appreciated. On the other hand, twenty-two patients had a positive
exploration of the contralateral groin and, while it is unclear how many of these PPV would
proceed to manifest themselves as metachronous hernias, it is clear that evaluation of the
contralateral groin reduces the need for a second operation in many of these patients.
COMPLICATIONS OF LAPAROSCOPIC INGUINAL HERNIA REPAIR
Secondary Hydrocele
Hydroceles can occur after the laparoscopic approach particularly if the contents of the
inguinal canal are not evacuated prior to closing the internal ring. Trapped air or fluid in the
inguinoscrotal region may evolve into an iatrogenic hydrocele if it goes unnoticed. This
complication is infrequent (0.7%-1.7%) and can be managed with observation in most
instances [Dutta and Albanese, 2009; Choi et al., 2012].
The Role of Laparoscopy in the Repair of Pediatric Inguinal Hernias
87
Reprinted with permission from Dutta, S., Albanese, C.(2009). Transcutaneous laparoscopic hernia
repair in children: a prospective review of 275 hernia repairs with minimum 2-year follow-up.
Surg. Endosc. 23:103–107.
Figure 6. Line diagram of the SEAL (subcutaneous endoscopic assisted ligation of the hernia sac)
pediatric inguinal hernia repair (right side shown).
Hematoma
Minor bleeding can occur during passage of the needle to encircle the internal ring if
injury to small bridging vessels, the inferior epigastric vessels, or the testicular vessels occurs.
This is managed by completing the pass of the needle and tying the suture. Occasionally
(2.2%) a small hematoma develops but ultimately resolves spontaneously [Dutta and
Albanese, 2009].
Damian Maxwell and Robert Baird
88
Testicular Atrophy and vas Injury
Decrease in testicular size has been reported rarely (0.2%) after the laparoscopic
approach, which compares favorably to reports as high as 19% after the open approach [Shier,
2006; Dutta and Albanese, 2009; Coran et al., 2012]. The testicular blood supply may be
compromised when encircling the internal ring and subsequently induce some amount of
ischemia to the testicle. Recognizable injury to the vas is 0%-0.2% in most series of
laparoscopic hernia repair [Shier, 2006; Dutta and Albanese, 2009]. Understandably, the
technique is relatively new and the long-term fertility rates and functional outcomes are
unknown. However, the absence of traction injury to the vas or testicular vessels with
laparoscopy may theoretically reduce the long-term morbidity associated with traditional
hernia repairs. Table 1 provides a comparative review of the literature evaluating testicular
atrophy and/or injuries to the recognized injuries to the vas deferens.
Recurrence
One of the major criticisms of laparoscopic inguinal hernia repair in children is the
potential for an increased recurrence rate, which in early reports were significantly higher
than the traditional open approach. There have been steady improvements in recurrence rates
with refinement of the surgical techniques. Initial reports of 4% were not unusual but have
since dropped to 1% or less in contemporary reviews [Shier, 2006; Endo et al., 2009]. With
the transition from the intraperitoneal to the extraperitoneal approach there has been a
precipitous drop in both ipsilateral and contralateral recurrences [Endo et al., 2009].
Causative factors include surgeon inexperience, improper technique, suture breakage,
underlying comorbidities, incarceration and prematurity. As surgeons have gained more
experience with the techniques, and adhered to more stringent patient selection, the risk of
recurrence has decreased. As with the open technique, patients with incarcerated hernias still
face increased recurrence rates due mostly to the inflamed tissue around the internal ring.
Laparoscopy is somewhat protective however in preventing and virtually eliminating the risk
to the vas deferens and the testicular vessels, which remain a major concern in open repairs
for incarceration. Similarly, premature infants often have extremely thin and friable hernia
sacs and frequently have concomitant chronic lung disease, which also place them at
increased risk [Baird et al., 2011]. Chan et al. [2013] showed that laparoscopic hernia repair is
safe in premature infants, but patient selection, and, more importantly, body weight, should be
considered when scheduling repair. Considering all of these variables, contemporary reviews
show recurrence rates to be comparable to traditional open repairs [Endo et al., 2009; Dutta
and Albanese, 2009]. Table 2 summarizes the contemporary literature comparing recurrence
rates for both techniques. A clinical trial currently underway will be enrolling approximately
150 subjects and will be evaluating laparoscopic versus open inguinal hernia repair in
children less than three years of age [Azikhan, 2013]. This will provide direct comparative
evidence in a relatively unbiased manner that will increase understanding of the advantages
and disadvantages of the laparoscopic approach, particularly for younger patients.
The Role of Laparoscopy in the Repair of Pediatric Inguinal Hernias
89
Table 1. Injury to the vas deferens or vessels based on approach,
laparoscopic versus open repair
Laparoscopic
Open
Author
# of
hernias
Injury to
vas or
vessels
Author
# of
hernias
Injury to
vas or
vessels
Dutta and Albanese, 2009
N=275
0%
Sparkman, 1962
N=313
1.6%
Schier, 2006
N=545
0.2%
Steigman et al, 1999
N=7314
0.2%
Baird, 2013
N=113
0%
Coran et al, 2012
N/A
2.6%-5%
Table 2. Recurrence rates of laparoscopic versus open inguinal hernia repair
Laparoscopic
Open
Author
Technique
# of
hernias
Recurrence
Author
# of
hernias
Recurrence
Lee and Liang
2002
extraperitoneal
N=450
0.8%
Schroder et
al., 2004
N/A
0.8%
Schier, 2006
intraperitoneal
N=542
4.1%
Coran et
al., 2012
N/A
<1%
Dutta and
Albanese,
2009
SEAL
N=275
1.5%
Ein et al.,
2006
N=6361
1.2%
Endo et al.,
2009
extraperitoneal
N=1257
0.2%
Takehara et
al., 2006
extraperitoneal
N=972
0.7%
Baird, 2013
SEAL
*
N=113
2.6%
*
SEAL: Subcutaneous Endoscopic Assisted Ligation of the hernia sac.
Miscellaneous Complications
Complications that are specific to the laparoscopic approach include port site hernias and
bowel injury. Since additional incisions are made for port access through the abdominal wall
there is a small risk of port site hernias occurring at these sites (1.5%) [Choi et al., 2012]. A
theoretical risk of intestinal injury exists, especially with the blind Veress needle technique.
However, the literature reviewed for this chapter does not reveal any such injuries, and the
senior author of this chapter has not encountered this in his practice. Care is paramount in
placing ports in a secure and stereotyped fashion to absolutely minimize complications not
otherwise associated with an inguinal hernia repair.
ADOLESCENT HERNIA REPAIR
There is no consensus in the literature regarding how to approach inguinal hernias in
teenage patients. The pathophysiology of the hernia seems related to those of younger
children however the recurrence rates after the open high ligation technique is four times
higher. In his review of over six thousand patients over 35 years, Ein et al [2006] found a
Damian Maxwell and Robert Baird
90
recurrence rate of 5% in teenage patients, compared to 1.2% for younger patients. This
incidence is hard to explain but may be related to increased post-operative activity,
underappreciated dilation of the internal ring, or missed direct hernias. Patrick et al. [2002]
showed a 0% recurrence rate in his series of 35 teenagers with indirect inguinal hernias
managed with a polypropylene mesh plug in the internal ring and a mesh overlay of the
posterior wall of the inguinal canal. It stands to reason that applying the adult-type totally
extra-peritoneal (TEP) mesh repair would also be successful in these patients and we use this
approach in our patients. As of 2012, four patients have been treated in our series with TEP,
without recurrence or other complication.
CONCLUSION
Minimally invasive techniques continue to transform the field of surgery and have
resulted in a myriad of novel approaches and instrumentation to treat traditional surgical
diseases. As surgeons gain more experience and comfort with these changes, outcomes will
likely continue to demonstrate perceived and as-of-yet unperceived benefits derived from
laparoscopy. These will no doubt stem from continued technological refinements (high
definition monitors, smaller and more user-friendly instrumentation), but also from improved
familiarity with the possibilities and limitations of the camera as well as an earlier mastery of
the laparoscopic surgery learning curve. This contemporary review of the literature supports
the ongoing improvements being made in laparoscopy for children. While complication rates
appear comparable to the traditional approach in experienced hands, the ability to either
exclude or treat a contralateral patent processus vaginalis underscores the utility of
laparoscopy for pediatric inguinal hernia repair.
REFERENCES
Azikhan, F. (2013). Trial of Laparoscopic Compared to Open Inguinal Hernia Repair in
Children Younger Than 3 Years. http://www. clinicaltrials. gov/ct2/show/NCT00716768?
term=pediatric+inguinal+hernia&rank=7. Accessed on May 20, 2013.
Baird, R. (2013). Personal communication.
Baird, R., Gholoum, S., Laberge, J. M. & Puligandla, P. (2011). Prematurity, not age at
operation or incarceration, impacts complication rates of inguinal hernia repair. J.
Pediatr. Surg., 46, 908-911.
Blatnik, J. A., Harth, K. C., Krpata, D. M., Kelly, K. B., Schomisch, S. J. & Ponsky, T. A.
(2012). Stitch versus scar--evaluation of laparoscopic pediatric inguinal hernia repair: a
pilot study in a rabbit model. J. Laparoendosc. Adv. Surg. Tech., A 22, 848-851.
Boley, S. J., Cahn, D., Lauer, T., Weinberg, G., & Kleinhaus, S. (1991). The irreducible
ovary: a true emergency. J. Pediatr. Surg., 26, 1035-1038.
Bronsther, B., Abrams, M. W. & Elboim, C. (1972). Inguinal hernias in children—a study of
1,000 cases and a review of the literature. J. Am. Med. Womens Assoc., 27, 522-525.