Efficacy of laparoscopically assisted high ligation of patent processus vaginalis in children

Summary

Introduction

Laparoscopic hernia repairs have been proven to be efficient and safe for children, despite the slightly higher recurrence rate compared with the classic surgical repair. They have the advantage of easy and precise identification of the type of defect and its correction, both in ipsilateral and contralateral sides.

Objectives

The objectives of this study were to evaluate the efficacy, safety and outcome of the laparoscopically assisted piecemeal high ligation of a patent processus vaginalis (PPV) in children.

Methods

A total of 40 children were enrolled into this prospective study; they were aged ≥6 months and had an inguinal hernia. The peritoneal cavity, including the contralateral side, was inspected for the possibility of bilateral hernias using a 3-mm 30° telescope. Another 3-mm port was introduced through the same infra-umbilical incision. The hernia was manually reduced or with the aid of a working infra-umbilical grasper. A prolene or vicryl 2/0 or 3/0 suture on a curved semicircle round-bodied taper-ended 25–30 mm needle was introduced through a very small inguinal skin-crease incision. It was passed through the abdominal wall layers to the peritoneum and was manipulated by the laparoscopic grasper to pick up the peritoneum in piecemeal all around the internal ring. The needle was then pushed to the outside near to the entrance site, thus forming a semicircle around the internal ring. The suture was then tied and the knot was subcutaneously buried.

The primary outcome of the procedure was the incidence of intraoperative diagnosis and surgical repair of contralateral hernias in pre-operatively diagnosed unilateral cases. The secondary outcomes were defined as the incidence of complications and hernia recurrence.

Results

Table. Patients demographics, operative time and post-operative hospital stay.

Age (years)			3.4 ± 1.8
Side	Right		28 (48.3%)
	Left		20 (41.7%)
Laterality	Pre-operative	Unilateral	32 (80%)
		Bilateral	8 (20%)
	Intra-operative	Unilateral	23 (67.5%)
		Bilateral	17 (32.5%)
Operative time (minutes)	Unilateral		25 ± 4
	Bilateral		34.6 ± 3.8
Hospital stay (hours)			4.3 ± 1.5

Discussion

The exploratory laparoscopy found contralateral patent processus vaginalis (CPPV) with a detection rate of 28.1%. Chan et al., Esposito et al., Toufique et al. and Niyogi et al. reported similar figures for laparoscopic contralateral hernia detection rates of 28%, 39%, 39.7% and 29.2%, respectively.

The limitations of this study were the small sample size, plus the risk factors and clinical significance for CPPV.

Conclusion

Laparascopically assisted piecemeal closure of the internal inguinal ring in children is a safe and effective procedure. It helps in detecting a contralateral hernia without prolonging the operative time.

Introduction

Laparoscopy has been a corner stone in the diagnosis and management of impalpable testes in children. The increased use of laparoscopic techniques in managing different urologic diseases has provided many benefits for children [1]. The routine method of surgical treatment for patent processus vaginalis in children has been herniotomy through an inguinal incision [2]. The reported recurrence rate for conventional open hernia repair in children is 0.8–3.8% and the postoperative contralateral hernia rates are 5.6–30% [3]. However, the trend has moved towards the application of laparoscopic techniques for pediatric hernia repairs [4].

Laparoscopic hernia repair in children has proven to be efficient and safe, despite the slightly higher recurrence rates compared with the classic surgical repair [5]; it has the advantage of easy and precise identification of the type of defect and its correction, both in ipsilateral and contralateral sides. Modern laparoscopic techniques have made ligation of the internal ring with a single port more feasible [6]. The debate about whether the laparoscopic approach for an indirect inguinal hernia should replace the standard surgical procedure still exists. The present study aimed to evaluate the efficacy, safety and outcome of the laparoscopically assisted piecemeal high ligation of a patent processus vaginalis in children.