Laparoscopic completely extraperitoneal repair of inguinal hernia in children: a single-institute experience with 1,257 repairs compared with cut-down herniorrhaphy

Conventional open herniorrhaphy has a problem of whether contralateral exploration is necessary in children with an indirect hernia [9]. Laparoscopic hernia repair resolves this question with opportunity to close both PPVs simultaneously, when a cPPV is found, without the addition of a crease incision on the opposite side. The second problem is postoperative hernia recurrence. The main factors affecting recurrence have been recognized as (1) failure to ligate the sac high enough at the internal ring; (2) injury to the floor of the inguinal canal due to operative trauma; (3) failure to close the internal ring in girls; and (4) postoperative wound infection and hematoma [10]. The laparoscopic technique has proven to be a method that can avoid all these possible causes of recurrence [11]. The third problem is injury to the reproductive system. Childhood inguinal herniorrhaphy has been said to be one of the most frequent causes of infertility [12].

The goal of our project was based on the principle of the traditional cut-down technique, which involves completely extraperitoneal high ligation of the PPV, minimizing the above-mentioned drawbacks with a simple technique. We devised the needles to accomplish circumferential ligation of the PPV via the extraperitoneal route more easily, safely, and completely. The needle goes beneath the ligamentum teres uteri distal to the U-turned ovarian duct in girls, involving the ligament inside of the ligature. To avoid damage to the spermatic cord and testicular vessels in boys, the needle is advanced between the peritoneum and cord and vessels.

At the preoperative guidance session, three methods were proposed to the patients’ parents: traditional cut-down repair, additional diagnostic laparoscopy for contralateral IIR inspection with simultaneous closure of a cPPV, and laparoscopic repair. The parents chose the laparoscopic repair more frequently based on the reasons described in the Results, which were occasioned by the predominance of girls and associated morbidities of the umbilicus in the LPC group. The parents were very satisfied with the wound cosmesis in LPC group patients. Hand-in-hand with experience-related advances in technique and patient feedback to family doctors, the incidence of LPC being chosen has markedly increased and the procedure garnered the position of the new standard of herniorrhaphy in our hospital.

Regarding the intraoperative findings, incidences of cPPV have been reported to range from 20–40% [13, 14, 15, 16]. The outstanding point in our series was the difference of cPPV rates between the CDL (21.6%) and LPS (47%) groups. This difference might be due to the technical differences of laparoscopic examination. In diagnostic laparoscopy during the cut-down procedure, an endoscope was inserted through the ipsilateral hernia sac with or without an assistant grasper. On the other hand, during an LPS procedure the laparoscope through the umbilicus is capable of visualizing both IIRs directly and always with the assistance of a grasper. Grossmann et al. described some difficulty in visualization of the contralateral side with an endoscope inserted from the ipsilateral hernia sac [17]. Furthermore, after experiences of contralateral development of clinical hernia in two girls, we have adopted more strict criteria for negative cPPV in LPC.

The average operation time for a unilateral hernia in the LPS group was comparable with the CD group, but was shorter for bilateral hernias. According to the difference in time between unilateral and bilateral closure, the time needed for closure of the IIR itself accounted for 8 min. The time for diagnostic laparoscopy via an ipsilateral hernia sac in cut-down herniorrhaphy was calculated at 6 min, which is compatible with a previous report [13]. Differences in time between boys and girls came from the care required around the spermatic cord. Because of tight contact between the spermatic cord and the peritoneum, separation of these structures in advance using electrocautery and a grasper is advisable, although in skilled hands, this step can be abridged, the result of which saves 4 min for a unilateral repair.

As for postoperative complications, contralateral hernia developed in eight children who underwent LPC or CDL. The patency had been overlooked in two of them because of a peritoneal veil covering the orifice completely. The remaining six children had had a pinhole orifice or shallow depression, development of a metachronous hernia from which was not thought to occur. The incidence of metachronous hernia of children who underwent laparoscopic inspection was 1.1%, which was far less compared with reported traditional unilateral open repair.

It is very difficult to eradicate postoperative recurrence as a fate of herniorrhaphy. Despite the fact that the laparoscopic approach theoretically provides high ligation of the PPV more proximally than open repair, higher rates of recurrence have been reported with this approach. Laparoscopic repairs involving closure of the hernia opening by suturing within the abdominal cavity in the pursestring or Z-type suture fashion where the suture material is tied off intracorporeally may have an intrinsic risk of reopening the vaginal process, leading to the recurrence of the hernia or development of a hydrocele. Reported recurrence rates were 3.1–4.4% [18, 19, 20]. In another procedure in which a circuit suture was placed extraperitoneally around the hernial orifice, crossing over the spermatic cord or the testicular vessels to leave them untouched and spare them from injury, small spaces are left above these structures. Reported recurrences in these techniques are 0.8–2.8%, which is lower than intraperitoneal closures [21, 22, 23]. Methods that allow complete encircling of the PPV, such as the intraperitoneal pursestring stitch passing between the peritoneum and the cord and vessel structures so as not to leave any skipped area, or a laparoscopic technique that produces every step of the open procedure involving complete division and stitching up of the PPV at the IIR, achieved the lowest recurrence rate from 0–1.3% [11, 24].

Our technique has fundamentally the same concept as the latter-mentioned techniques, but with more simplicity. Hernia recurrence occurred in two boys in the LPC group (0.2%): one due to early rejection of the suture, and the other due to provable loosening of the suture knot, prompting a modification in technique. The modification was made by double-ligation of the proximal end of the sac for infants younger than 1 year 6 months in whom the external inguinal ring is located so close to the IIR that the shortened inguinal canal becomes uncovered by musculature and is vulnerable to increased intra-abdominal pressure. The doubly ligated IIR is expected to hold against pressure until wound healing is completely accomplished.

Drawbacks associated with the reproductive system are a hidden but not negligible problem. One report suggests that vas deferens or epididymis was found in 0.53% of hernial sacs removed during herniorrhaphy [25]. The incidence of vasal injury during inguinal herniorrhaphy has been estimated at 0.5% [26]. Fallopian tube obstruction in a woman with a history of childhood bilateral inguinal herniorrhaphy was reported as the cause of infertility [27]. We had two episodes of injury to the reproductive system during cut-down repair. In addition, testicular atrophy, ascent of the testis, ovarian malposition, and bladder injury have been reported, none of which occurred in our laparoscopic series.

Despite increasing reports regarding the laparoscopic approach, there has been only one comparative study between laparoscopic and open repair. Chan et al. emphasized the superiority of laparoscopic repair from the points of less pain, prompter recovery, and better cosmesis [28]. Operation times were longer for unilateral and equal for bilateral repair compared with open repair. In our series, the majority of parents preferred laparoscopic repair based on postoperative cosmetic superiority, bilateral IIR inspection, and simultaneous repair for an unpleasant-looking umbilicus. Laparoscopic operation times were equal for unilateral and shorter for bilateral repair compared with open repair. There was no injury to the reproductive system in contrast to the cut-down procedure. Postoperative recurrence and contralateral hernia were less in the laparoscopic group, although we could not achieve 0% incidence.