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Ventral Hernia Repair
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There were 43 cases (15.7%) of early seroma, 18 in the IH group, 20 in the UH group,
and 5 in the VH group, who underwent conservative treatment, with good results and
spontaneous resorption. No drainage was performed (to prevent the risk of mesh infection).
Follow-up time ranged from 1 to 86 months (mean follow-up time: 7.1 months). Eleven
patients had a recurrent hernia, 8 in IH repair, 2 in UH repair, one in VH repair. The overall
recurrence rate was 4%. There was no incisional hernia at the trocar site.
DISCUSSION
The laparoscopic approach to abdominal wall defects has progressively become a
standard for many surgical teams. This is certainly related to the increased ability of surgeons
to perform advanced laparoscopic procedures as well as to the availability of modern non-
adherent meshes. Our experience follows the same evolution as the one demonstrated by the
increased proportion of patients operated on by laparoscopy in our unit in recent years (Figure
1). The laparoscopic approach follows the principles established by modern approach
pioneers in the management of abdominal wall defects [Rives et al., 1985; Stoppa, 1989]. The
main difference related to the laparoscopic route concerning posterior approach principles is
mesh positioning into the peritoneal cavity although the technique was initially described with
the mesh placed behind the aponeurosis in contact with the muscles.
There is also a debate concerning the type of defects that must be treated
laparoscopically, as ventral hernias and umbilical hernias are different pathologies. In fact,
the pathophysiologies of an umbilical defect and of a postoperative ventral hernia are distinct.
Nevertheless, the principles of the surgical approach to these defects are comparable, as they
all follow tension-free repair principles and as a mesh is placed intraperitoneally with a wide
overlapping of defect edges. Consequently, the standard analysis of operative results may be
performed for both indications, even if some data can be analysed for each indication
individually when compared to the results of published series.
In our series, 106 patients were operated for an umbilical hernia repair. This approach
was decided upon after discussion with the patients. The major reason to select this approach
was to preserve the cosmetic aspect of the umbilicus after surgery, and especially so in obese
patients in whom this repair is difficult to perform [Tsereteli et al., 2008; Itani et al., 2010;
Colon et al., 2013; Liang et al., 2013]. Concerning incisional hernia, our indications are
currently well-defined, and we only include patients presenting defects less than 10 cm in
diameter without large widening of the rectus muscles. In fact, in these patients, cosmetic
results may be unsatisfactory as the mesh is directly molded onto the hernia wall, contrary to
treatment of defects having a fibrotic ring in which the mesh bridges the defect. Patients with
a 10 cm distance between the rectus muscles may benefit from an abdominal wall
reconstruction, possibly completed by a compartmental repair. The ideal indication remains a
ventral hernia in patients with a single or multiple hole(s) but with a clear hernia ring and a
protrusive hernia. The specificity of the laparoscopic mesh positioning as compared to every
open approach is the placement of the mesh into the abdomen. The mesh is in direct contact
with the bowel and the omentum. The literature demonstrates that there are currently many
Didier Mutter, Stefano Mandala and Jacques Marescaux
72
options available for these meshes [Tanaka et al., 2007]. These should combine two
properties. The first property is the need to provide a highly resistant mesh, presently mainly
composed of polypropylene or polyester. These two biomaterials are known to induce
significant adhesions to intra-abdominal organs (i.e., colon, small bowel) [Heniford et al.,
2003], and they are consequently all combined with non-adhesive products including oxidised
regenerated cellulose, polyglecaprone or collagen to prevent these postoperative adhesions.
Our choice is presently oriented towards Parietex™ composite meshes (Covidien, Inc.
Mansfield, MA, USA) associating very resistant polyester with a protective non-adherent
collagen layer which is quickly integrated into a new peritoneal layer.
We have standardised our techniques in order to make them reproducible by our surgical
team including fellows and senior surgeons. Critical points first include port position. As we
wish to obtain large overlays over hernia defects with a minimal distance of 5 cm, we place
our first port 7 cm away from the edges of the defect. This port position is usually located on
the left side as the left colon typically has fewer parietal adhesions than the right one. This
allows a good exploration of the abdomen and an ideal positioning of the two 5 mm working
trocars placed on the right and on the left side of the first one at the same distance from the
defect.
The second issue concerns whether the hernia sac should or should not be removed. After
some attempts to completely remove the sac, we observed more postoperative hematomas and
no benefit in terms of postoperative seroma. We decided to simplify our technique as much as
possible, and currently recommend against systematic sac removal. As we perform tension-
free repair without closure of the defects, there is a risk of simultaneous peritoneum and mesh
migration into the sac after the repair. For this reason, we follow the rule established by many
other teams to place a minimum of 4 transfascial stitches fixing the edges of the mesh through
the whole parietal wall. This allows ideal mesh positioning and also prevents early mesh
migration as it is fixed 5 cm away from the edges of the defect. This technique is also very
easy to perform, and our series did not show any conversion. Transfascial stitches do not
allow placing the mesh closely in contact with the peritoneum, and this fixation is completed
by absorbable tackers placed every 1 to 2 cm around the mesh in order to prevent bowel
migration between the mesh and the parietal wall. Here again, our experience did not show
any recurrence due to the migration of the bowel between the mesh and the peritoneum. The
recurrence observed was due to mesh migration into the defect. Finally, a criticism expressed
by some authors regards the need to perform a new 12mm incision in the flank, potentially at
risk for a new hernia. In our series, we never observed any hernia at the trocar insertion site.
This is probably due to the dissection of the different layers instead of divisions to access the
abdomen, combined with careful closure of the incision. Our series is based on prospectively
acquired data. This study, however, is reliable only to a certain extent, as it is not a
prospective comparative study with other techniques but really reflects our experience.
Consequently, our results can only be compared to those published in the literature [Heniford
et al., 2003; Forbes et al., 2009; Itani et al., 2010; Eker et al., 2013]. The main follow-up data
usually studied in our series are firstly the potential recurrence risk, and secondly
postoperative pain, seroma, and patient comfort. Contrary to other series in the literature, our
series presents a low recurrence rate of 4%. This rate will probably increase with a longer
follow-up. However, it is still comparable to that of other series in the literature and
Ventral Hernia Repair
73
significantly lower than the ones observed in series evaluating open approaches. The results
of large multicentric randomized control trial comparing laparoscopy with open surgery
reflected an overall recurrence rate of 17% whereas the laparoscopic group only had a 14%
recurrence rate [Eker et al., 2013]. More specialized teams have, however, reported better
results. A recurrence rate below 5% has been reported in different series and appears to be the
standard for laparoscopy [Heniford et al., 2003; McKinlay and Park, 2004]. The same range
of results was observed in the series of umbilical hernia repair [Colon et al., 2013]. The high
recurrence rate observed by Itani et al. [2010] appears to be lower than the one after an open
approach with a 12.5% recurrence rate. One potential drawback of the laparoscopic approach
may be the higher rate of seroma formation, as the sac is not resected and the defect is left
open. In fact, mesh position associated with tension-free repair is at the origin of persistent
areas rapidly filled by seroma fluid postoperatively. All attempts to totally avoid seroma,
including glue, drainage or suturing failed. In most series, the early seroma rate is high but in
most cases, seromas disappear rapidly. The rate of seroma observed after 6 months in our
series is approximately 15.7%, which is a rate slightly higher than the one observed in the
literature [Heniford et al., 2003; Forbes et al., 2009; Itani et al., 2010; Eker et al., 2013]. This
is probably due to the fact that we systematically evaluated the presence of seroma clinically,
even small seromas without any patient complaint. Indeed, we found that patients have very
few complaints concerning such seromas if they are informed of the occurrence risk, and
seromas still decrease in volume quickly after a few months. We did not have any patients in
our series request re-operation due to the presence of remaining seroma.
Postoperative pain is also very limited, and only 18 patients complain of moderate long-
lasting discomfort or pain associated with repair. Here again, no further infiltration or
medication was required later in time.
The complication rate includes intraoperative and postoperative complications.
Intraoperative complications were mainly observed in one patient with a small bowel injury
treated by re-operation. This is a rare complication related to extensive dissection which could
represent the limits of the technique. This complication is not specific to laparoscopy; it is
rare but classically described in open or laparoscopic approaches [Ferrari et al., 2013]. Other
early postoperative complications are also mainly related to dissection (haematoma,
superficial wall infection). We did not observe any mesh infection which appears to be a
noteworthy result. No long-term complications were observed in our series.
CONCLUSION
The analysis of this series of 273 patients operated on for ventral hernia defects
demonstrates the feasibility, safety, and effectiveness of the laparoscopic approach. The
surgical procedure is easily reproducible and allows for a very short hospital stay. Most
patients are discharged on the second postoperative day. Postoperative complications occur in
our series. These occurrences are, however, lower than those observed in the literature. The
main limitation of this study is the short postoperative follow-up as it is well-established that
recurrence may occur up to five years postoperatively.
Didier Mutter, Stefano Mandala and Jacques Marescaux
74
DISCLOSURE STATEMENT
The authors declare that no financial or other conflict of interest exists in relation to the
content of the article.
ACKNOWLEDGMENT
The authors are grateful to Christopher Burel, Camille Fischer, and Guy Temporal for
their editing assistance.
REFERENCES
Colon, M. J., Kitamura, R., Telem, D. A., Nguyen, S. & Divino, C. M. (2013). Laparoscopic
umbilical hernia repair is the preferred approach in obese patients. Am. J. Surg., 205,
231-236.
Eker, H. H., Hansson, B. M. E., Buunen, M., Janssen, I. M. C., Pierik, R. E., Hop, W. C.,
Bonjer, H. J., Jeekel, J. & Lange, J. F. (2013). Laparoscopic vs open incisional hernia
repair. A randomized clinical trial. JAMA Surg., 148, 259-263.
Ferrari, G., Bertoglio, C., Magistro, C., Girardi, V., Mazzola, M., Lernia, S. D. & Pugliese, R.
(2013). Laparoscopic repair for recurrent incisional hernias: a single institute experience
of 10 years. Hernia [Epub ahead of print] DOI 10.1007/s10029-013-1098-3.
Forbes, S. S., Eskicioglu, C., McLeod, R. S. & Okainec, A. (2009). Meta-analysis of
randomized controlled trials comparing open and laparoscopic ventral and incisional
hernia repair with mesh. Br. J. Surg., 96, 851-858.
Heniford, B. T., Park, A., Ramshaw, B. J. & Voeller, G. (2003). Laparoscopic repair of
Ventral Hernias Nine years’ experience with 850 consecutive hernias. Ann. Surg., 238,
391-400.
Itani, K. M., Hur, K., Kim, L. T., Anthony, T., Berger, D. H., Reda, D. & Neumayer, L.
(2010). Comparison of laparoscopic and open repair with mesh for the treatment of
ventral incisional hernia. A randomized trial. Arch. Surg., 145, 322-328.
LeBlanc, K. A. (2005). Incisional Hernia Repair: Laparoscopic Techniques. Word J. Surg.,
29, 1073-1079.
LeBlanc, K. A. & Booth, W.V. (1993). Laparoscopic repair of incisional abdominal hernias
using expanded polytetrafluoroethylene: preliminary findings. Surg. Laparosc. Endosc.,
3, 39-41.
Liang, M. K., Clapp, M., Li, L. T., Berger, R. L., Hicks, S. C. & Awad, S. (2013). Patient
satisfaction, chronic pain and functional status following laparoscopic ventral hernia
repair. World J. Surg., 37, 530-537.
McKinlay, R. D. & Park, A. (2004). Laparoscopic ventral incisional hernia repair: a more
effective alternative to conventional repair of recurrent incisional hernia. J. Gastrointest.
Surg., 8, 670-674.
Rives, J., Pire, J. C., Flament, J. B., Palot, J. P. & Body, C. (1985). Treatment of large
eventrations. New therapeutic indications apropos of 322 cases. Chirurgie., 111, 215-225.
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Stoppa, R. E. (1989). The treatment of complicated groin and incisional hernias. World J.
Surg., 13, 545-554.
Tanaka, K., Mutter, D., Inoue, H., Lindner, V., Bouras, G., Forgione, A., Leroy, J.,
Aprahamian, M. & Marescaux, J. (2007). In vivo evaluation of a new composite mesh
(10% polypropylene J. Mater. Sci. Mater. Med., 18, 991-999.
Tsereteli, Z., Pryor, B. A., Heniford, B. T., Park, A., Voeller, G. & Ramshaw, B. J. (2008).
Laparoscopic ventral hernia repair (LVHR) in morbidly obese patients. Hernia., 12,
233-238.
Turner, P. L. & Park, A. E. (2008). Laparoscopic repair of ventral incisional hernias: pros and
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In: Hernias ISBN: 978-1-62948-441-9
Editor: Mark A. Suckow © 2014 Nova Science Publishers, Inc.
Chapter 6
THE ROLE OF LAPAROSCOPY IN THE REPAIR OF
PEDIATRIC INGUINAL HERNIAS
Damian Maxwell and Robert Baird
*
Department of Pediatric General and Thoracic Surgery
Montreal Children's Hospital, McGill University, Montreal, Canada
ABSTRACT
Inguinal hernia repair remains the most commonly performed elective procedure by
pediatric general surgeons. Countless children have been afflicted by this common
embryologic abnormality, and while most have uneventful pre and post-operative
courses, incarceration, strangulation and even intestinal loss or death can complicate the
presentation. Furthermore, operative repair occasionally results in serious adverse
complications with potential life-long repercussions. This chapter reviews the
pathophysiology, epidemiology, presentation and treatment of inguinal hernias in
children, with a special focus on the emerging role of laparoscopy. The technique will be
reviewed, and advantages and disadvantages will be discussed through comparing
complication rates with the traditional approach to inguinal hernia repair.
Keywords: Inguinal hernia, laparoscopy, pediatric, pathophysiology, management
INTRODUCTION
The pathophysiology and subsequent management of pediatric inguinal hernias has
remained largely unchanged for the last one hundred years. The incidence in children ranges
from 0.8 to 4.4% with the highest incidence occurring in premature infants (16%- 25%)
[Walsh, 1962; Bronsther et al., 1972; Rajput et al., 1992]. Outside of premature infants, a
distinct male predilection has been appreciated, with up to a 10:1 gender difference reported
[Rajput et al., 1992]. The diagnosis of an abnormal swelling on the surface of the belly or
*
Corresponding author: Department of Pediatric General and Thoracic Surgery, Montreal Children's Hospital,
McGill University, Montreal, Quebec, Canada. Email: robert.baird@mail.mcgill.ca.
Damian Maxwell and Robert Baird
78
groin has been recognized since antiquity; the traditional management described by Marcy
dates back to 1871, who recognized the key steps of high ligation of the hernia sac with
preservation of the spermatic cord structures. For decades, the surgical repair has involved a
variation of the repair as originally described by Marcy and popularized by Ferguson towards
the turn of the 20th century [Ferguson, 1899]. With minor variations dependent on operator
preference, the procedure involves an oblique groin incision, identification and opening of the
external oblique aponeurosis to reveal the inguinal canal, dissection of the hernia sac from the
cord structures (in males) followed by suture ligation of the sac at its neck, close to the
internal ring. This time-tested approach has resulted in a recurrence rate of <1% in the term
infant (15% for premature infants, 20% for incarcerated hernias), a vas deferens injury rate of
less than 1%, and a testicular atrophy rate of 1%- 2% with a reduction in testicular volume
approaching 13% [Glick et al., 2006; Grosfeld et al., 2006]. Despite the success rate of the
high ligation technique, a survey of over 440 pediatric surgeons reported by Levitt et al.
[2002] found that there are significant variations in this open surgical technique. The open
repair, and its permutations, have served countless children and remained the unchallenged
standard of care until the advent of minimally invasive surgical (MIS) techniques that began
to be reported in the early 1990’s. Innovations that enabled this new era included the mastery
of abdominal insufflation, improved illumination and optics and the invention of smaller
working instruments, all of which resulted in increased familiarity and accelerated learning
curves amongst practicing surgeons. These tools and techniques were quickly adopted to the
problem of inguinal hernias in an effort to address the known iatrogenic trauma inflicted in
gaining access to the contents of the inguinal canal through the open approach. In addition,
the advent of laparoscopy afforded the opportunity to improve upon the admittedly low but
real complications of ipsilateral recurrence, testicular atrophy, injury to the vas deferens or
spermatic vessels as well as the reoperation rate for metachronous contralateral hernias –
perhaps the most compelling argument for its widespread adoption.
EMBRYOLOGY
Congenital inguinal hernias result from a failure of the processus vaginalis (PV) to close
after birth. The processus begins to be formed as an out-pouching of the ventral abdominal
wall during the first trimester of fetal life [Clarnette and Hutson, 1996]. The genitofemoral
nerve hypothesis of hernia development links the inguinoscrotal phase of testicular descent
and gubernaculum migration to the production of calcitonin gene-related peptide (CGRP)
[Clarnette and Hutson, 1996]. These events are integral components implicated in the ultimate
location of the postnatal testis and the patency of the PV. The mechanism behind closure of
the processus remains unknown, but clearly requires the coaptation of mesothelial elements
leading to obliteration of the canal. This process may directly be influenced by CGRP
[Clarnette and Hutson, 1996]. Arrest or failure of these events can lead to hernias, hydroceles
and other variants (Figure 1). In females, the canal of Nuck corresponds to the anatomic
equivalent of the processus vaginalis in boys. This structure typically closes in the prenatal
period, but may remain patent and occasionally results in an inguinal hernia in a female.
The Role of Laparoscopy in the Repair of Pediatric Inguinal Hernias
79
Reprinted with Permission The clinical abnormalities of the failure of closure of the processus
vaginalis. (From Rowe MJ, Lloyd DA: Inguinal hernia. In Welch KJ, Ravitz M, Randolph JG, et al
(eds): Pediatric Surgery, ed 4. Chicago, Mosby Year Book, 1986, p 780).
Figure 1. Variations of inguinal anatomy in males.
Up to 80% of neonates will have a patent PV at birth and if obliteration is to occur, it
typically takes place within the first 6 months of life. The rates of patency decrease to 40% at
one year and continue to decrease and level off at 3-5 years of age [Rothenberg and Barnett,
1955; Snyder and Greaney, 1962]. There is a high rate of patency in patients with
undescended testis, which implies that closure of the processus vaginalis is dependent on
testicular descent.. It is unclear whether the closure begins distally, proximally or somewhere
in the middle [Clarnette and Hutson, 1996].
PRINCIPLES OF MANAGEMENT
Due to its embryological origin, an inguinal hernia will not resolve spontaneously. The
prime justification for prompt surgical correction is the significant rate of incarceration and
potential strangulation with loss of intestine, ovary or testicle. An increased risk of
incarceration is associated with younger patients given their inability to clearly articulate their
discomfort, while patients with a history of prematurity represent a particularly high-risk
group [Baird et al., 2011]. Timing of repair remains controversial, with traditional evidence
suggesting that complication rates can be minimized if treated within 1 month of diagnosis
[Wiener et al., 1996]. More recent literature has suggested that a more tailored approach to
scheduling operative repair is reasonable depending on patient age [Zamakshary et al., 2008;
Gholoum et al., 2010]. Irrespective of timing, the principles of operative repair include
reduction of hernia contents (if applicable), obliteration of the communication between
cavities and minimization of peri-operative complications and morbidity. The traditional
repair has addressed these goals in a seemingly satisfactory fashion for many years although
complications continue to be reported.
Damian Maxwell and Robert Baird
80
COMPLICATIONS OF OPEN HERNIA REPAIR
Secondary Hydrocele
After open inguinal hernia repair, inflammatory fluid can accumulate in the remaining
distal hernia sac forming a noncommunicating hydrocele in up to 11% of patients resulting in
a visible scrotal swelling [Davis et al., 2003].
This is of particular importance because it
results in a failure to meet expectations of the patient or their parents. Fortunately, these
collections usually resolve spontaneously over the ensuing 6 to 12 months. Rarely, persistent
collections may require a second procedure to aspirate collected fluid or excise the fluid filled
sac [Coran et al., 2012]. Inguinal ultrasound should be performed in this context which may
confirm or refute the presence of a recurrent hernia. Transumbilical laparoscopy may be
required for persistent collections to ensure there isn’t a recurrent inguinal hernia. Similarly,
blood can accumulate in this space secondary to a difficult dissection or unrecognized
intraoperative bleeding and present with progressive bruising and scrotal hematoma. If
recognized early, prompt re-operation is indicated.
Iatrogenic Cryptorchidism
Failure of the testis to be placed in, or to remain in, the scrotum is uncommon after hernia
repair but is probably an underappreciated and underreported complication. This results from
a failure to ensure the testis is well within the scrotum at the end of the procedure. This would
typically occur due to excessive traction on the spermatic cord in an attempt to isolate and
separate the hernia sac from the vas and vessels thereby pulling the testis into the inguinal
canal. An “ascending testis” may also be high riding and give the impression of
cryptorchidism [Hack et al., 2012]. Retraction and scarring of the testis high in the scrotum or
distal inguinal canal can result in a suboptimal postoperative location of the testis. With a
reported incidence of 0.2%, this complication is rare but would require a second procedure
including orchidopexy in most instances [Hecker and Ring-Mrozik, 1987; Esposito et al.,
2009].
Injury of the vas Deferens
Traction and crush injury to the vas deferens may not be realized unless the injury is
bilateral and results in infertility in adulthood. The incidence of injury to the vas, with
segments of vas deferens identified in specimens of hernia sacs after inguinal hernia repair,
have been reported as high as 1.6% in early literature[Sparkman et al., 1962]. Many of these
specimens however may have been Müllerian duct remnants and are of little clinical
significance. Most current reports of vas deferens injury range from 0.2% to 1.6% [Steigmen
et al., 1999; Dehner, 1999]. With an incidence this low many authors think it unnecessary to
perform pathological evaluation of inguinal hernia sacs since most instances of transection of
the vas can be appreciated at the time of surgery. If transection of the vas does occur it should
be repaired immediately, with 8.0 absorbable sutures, and the assistance of magnification. If