​​​​​​​Laparoscopic Repair of Pediatric Hernia - Dr. R.K. Mishra

Laparoscopic Repair of Pediatric Hernia

The first use of laparoscopy in cases of inguinal hernia in children was for diagnosis. Laparoscopic or transinguinal laparoscopic evaluation for a contralateral patent vaginalis process has been previously reported as a means of avoiding metachronous hernias. In these cases, the internal examination has been performed by laparoscopic technique, placing the optical trocar through the umbilicus. The main problem is to decide whether or not to treat the contralateral hernia sac immediately. Is the contralateral vaginalis process-wide and deep enough to be responsible in the short-term for a metachronous contralateral hernia?

During laparoscopy for inguinal hernia repair, the surgeon often encounters an unexpected bilateral hernia. This situation underscores the importance of laparoscopy as a means of improving the diagnosis of bilateral hernias. Femoral hernias are often misdiagnosed and treated as inguinal hernias. Thus, laparoscopic groin exploration is a valuable means of evaluating children with presumed recurrent inguinal hernias. Less than 1 percent of all groin masses seen in children are due to femoral hernias. Because these hernias are so uncommon, they are often overlooked, misdiagnosed, or even treated as inguinal hernias. In fact, the correct diagnosis of femoral hernia is often made at the time of groin re-exploration for a presumed recurrent inguinal hernia. The laparoscopic approach may offer better diagnostic ability than conventional open exploration because all potential hernial defects in both groins can be examined under direct laparoscopic vision. Furthermore, a unilateral or simultaneous bilateral tension-free repair can be done using the laparoscopic technique. Laparoscopy is helpful to diagnose a femoral hernia. It enables accurate identification of the nature of the groin defect. However, the technical details of laparoscopic femoral hernia repair are still under discussion, even in adult series. The role of laparoscopy in the management of suspected recurrent pediatric hernias has been described. For patients with a patent processus vaginalis, laparoscopy is efficient for diagnosis and treatment.

Which laparoscopic procedure is most efficient in pediatric surgery cases?

•    Ligature alone of the hernia sac without dividing the peritoneum. It has a high recurrence rate; this may due to the use of absorbable sutures or to the continuity of the peritoneum, which is left intact. Furthermore, the risk of injury to the vas or the vessels from the needle running under the peritoneum without previous dissection seems to be high.

•    Performing the procedure without ligature of the hernia sac while only dividing the peritoneum on the site of the inner inguinal ring, seems to be enough to avoid early complications and to achieve a low recurrence rate. But it may lead to intraperitoneal adhesions.

•    To avoid such adhesions, many surgeon operate the patent process vaginalis just like open surgery. The vaginalis process is divided by separating the sac, which remains in the scrotal pouch or in the labia majora, and the peritoneum at the internal inguinal ring. This procedure does not require the opening of the inguinal canal. Dissection of the vas and spermatic vessels is done at the level of the internal inguinal ring, where these elements are easier to spare from the peritoneum, whereas more adhesions may be encountered in the inguinal canal. The peritoneum is ligated. At the end of the procedure, one should pay close attention to the testis position, so as to avoid a secondary occurrence at an ectopic site. Pain and discomfort resolve very quickly. Laparoscopic herniorrhaphy in children is gaining increasing acceptance in pediatric surgery. The essential step in the conventional method for inguinal hernia repair in children is the simple ligation of the hernial sac without narrowing the open ring. The internal inguinal ring is reached by opening the inguinal canal and dissecting the hernial sac from the cord structures.  Postoperatively, the major damage from which the patient has to recover is not the ligature of the hernial sac, but the trauma of access itself. Therefore, the clinical goal is to leave the abdominal wall as intact as possible. Laparoscopy is most appropriate for this purpose to gain access to the abdominal cavity in order to close the inner inguinal ring from within. The laparoscopic repair of pediatric hernia requires 2 mm instruments; the use of larger instruments would lead to an increase in the size of the incision that would make it equivalent to a conventional groin incision. Bilateral inguinal hernias, as well as indirect and direct hernias, are of no concern in laparoscopic herniorrhaphy. There is no difference between the access and treatment for unilateral and bilateral laparoscopic hernia repair and the laparoscopic repair of a direct hernia. Needle for intracorporeal suturing is introduced through the abdominal wall in the case of a pediatric patient.

Purse string suture for pediatric inguinal hernia repair
Purse string suture for pediatric inguinal hernia repair

Port position for pediatric appendicectomy
Port position for pediatric appendicectomy

Needle should be introduced percutaneously in the pediatric age group
The needle should be introduced percutaneously in the pediatric age group

Because it remains unclear whether a small open processus vaginalis develops subsequently into a hernia, we choose to close open inner inguinal rings down to a 2 mm width whether they are unilateral or bilateral. In many patients, the contralateral side was found to be open as well; by closing these openings, it is assumed to exclude the possibility that hernias would occur.

The recurrence rate of inguinal hernias in children is slightly higher with laparoscopic herniorrhaphy than with the conventional technique. In patients with recurrences after laparoscopic herniorrhaphy, the surgeon has undisturbed anatomy for groin incision; the risk of an injury to the vas deferens, subsequent testicular atrophy, and the risk of superior displacement of the testicle seems less likely. In cases of hernia recurrence after conventional hernia repair, laparoscopy allows us to clearly differentiate an indirect hernia from a direct one. Direct inguinal hernias in children are not that rare. The cosmetic results are excellent. Once the technique of intracorporeal suturing in a limited space is mastered, laparoscopic herniorrhaphy is safe, reproducible, and technically easy for experienced laparoscopists. If there is any uncertainty about the contralateral side, whether it is a direct or an indirect hernia, and in cases of inguinal hernia recurrence, the laparoscopic procedure is highly preferable as a primary technique that combines diagnosis and the potential for immediate treatment.


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