Current concepts in the management of inguinal hernia and hydrocele in pediatric patients in laparoscopic era
Introduction
A surgical intervention for inguinal hernia (IH) and hydrocele is one of the most common operations performed in children.1 Inguinal hernia and hydrocele have a common etiology,2 and the surgical correction of both pathologies is similar.3 The advent of minimal access techniques has changed conventional management for the treatment of inguinal hernia in particular.4, 5 The incidence of inguinal hernia in children less than 18 years of age ranges from 0.8%–4.4%.6 About 85% of children with an inguinal hernia present with a unilateral hernia. The incidence of incarceration in untreated hernias in infants and young children varies between 6% and 18%, but it increases to approximately 30% in infancy.7
Bilateral inguinal hernia is significantly more common in younger patients with an incidence of about 50% in children younger than 1 year.8 In patients undergoing unilateral hernia repair, there is a 5%–20% chance that a hernia will develop on the contralateral side requiring a second operation and anesthesia for repair.8, 9 In the pediatric population, the traditional inguinal approach is an excellent method for hernia repair.10 However, there is a potential risk of injury to the spermatic cord and vas deferens, hematoma, wound infection, iatrogenic cryptorchidism, testicular atrophy, and recurrence of the hernia.11, 12
Laparoscopic inguinal hernia repair (LH) in children was introduced as an alternative to conventional open hernia repair (OH). It was first described by Montupet in 1993.13, 14 Many technical variations have been described for LH repair,15 and can be categorized as either intracorporeal or extracorporeal/percutaneous. Montupet initially described the technique of intracorporeal repair, consisting of a purse-string suture in the peri-orificial peritoneum at the level of the internal ring.4, 14 Schier13 introduced his technique, consisting of an “N”-shaped suture on the peri-orificial peritoneum. Becmeur et al.16 described laparoscopic division and resection of the hernia sac at the level of the internal ring, with subsequent closure of the peritoneal edges. The extracorporeal techniques all involve the placement of a suture circumferentially around the internal ring and tying the knot using percutaneous techniques.17
Many variations of this approach have been described. Recently, Ostlie and Ponsky reviewed the literature,4 and stated that there was insufficient evidence to support one approach over another. However, the addition of the peritoneal incision intentionally created at the level of the internal inguinal ring, as reported by Esposito,18 seems to result in a more durable repair.
The proposed advantages of the laparoscopic technique include visualization of contralateral defects, identification of less common (direct and femoral) hernias, diminished postoperative pain, improved cosmesis, more rapid return to normal function, and a lower rate of complications (particularly in infants and complex cases). Potential disadvantages include possible increase in length of operative time and costs, learning curves, and the need of orotracheal intubation for anesthesia.14 The indications for, and contraindications to LH are controversial and the superiority of LH versus OH continues to be debated.19, 20 This article aims to evaluate current concepts in the management of inguinal hernia and hydrocele in an era of minimally invasive surgery.
Section snippets
Diagnosis
The diagnosis of inguinal hernia is clinical. In general, patients with hernia are adequately assessed by history and physical examination.1 Their history often reveals the sudden, intermittent appearance of a bulge in the inguinal region or in the scrotum during diaper change or after bathing. Bulging is also usually seen during crying or with defecation.21 In cases of incarcerated hernia, an intestinal obstruction may be present, with vomiting and an abdominal distention. If the hernia is
Anesthesia
The majority of infants and children undergoing surgical treatment of hydrocele and hernia require pre-anesthetic medication and general anesthesia.25 Separation anxiety can be quite significant, and many factors (genetic, personality, previous experience, and parenteral anxiety) may influence its severity. Pre-anesthetic tranquilizing medications include the benzodiazepines and other agents. Oral midazolam is a common pre-anesthetic medication, with dose ranges of 0.25–1.0 mg/kg. Upon arrival
Surgical training
As a surgical trainee learns how to perform an inguinal hernia repair, the open technique is fairly straightforward—direct observation in the operating room, first helping an expert surgeon and then operating as the primary surgeon. Laparoscopic training for inguinal hernia repair is quite different.
According to European Society of Pediatric Endoscopic Surgeons Association (ESPES), a laparoscopic training program has to be completed before starting laparoscopic operations in human subjects. On
Inguinal hernia
Surgery is indicated for all pediatric patients in whom the diagnosis of inguinal hernia has been made. Most surgeons operate on premature infants with hernias prior to the infant׳s discharge from the neonatal intensive care unit.34 Infants younger than 6 months are usually booked on a soon-available operating list. Older children with few symptoms can be booked electively.35, 36 Surgical treatment is offered for inguinal hernia to prevent the complications of incarceration and obstruction,
Timing of surgery
As mentioned, infants younger than 3 months with IH are usually booked on a soon-available operating list and older children with few symptoms can be operated electively.35, 36, 40 In case of incarceration, if the hernia is able to be easily reduced and the child is older than 3 months, the procedure is usually carried out electively.
An attempt at reduction should be made in a patient who presents with an incarcerated hernia. Reduction should be performed by an experienced physician, using
Operative positioning
In open inguinal repair, the surgeon׳s position is ipsilateral to the pathology. However, with laparoscopic hernia repair the patient is always in supine position but with a 15°–20° Trendelenburg inclination to reduce the intra-abdominal pressure (IAP) and abdominal contents. The bladder should be emptied before surgery. The video column is positioned at the foot of the patient, the surgeon at the head of the patient, and the camera operator contralateral to the pathology (hernia).
Operative approaches to inguinal hernia and hydrocele
Inguinal hernia and hydrocele in children can be treated through either an open or laparoscopic technique.
Literature analysis
We performed a literature analysis using PubMed, Cochrane, and Medline databases on all studies published during the last 20 years that described open or laparoscopic operation for inguinal hernia, and the latter was compared to conventional OH. The following keywords were used: “inguinal hernia,” “herniorrhaphy,” “hernia repair,” “children,” “laparoscopic versus open herniorrhaphy,” “laparoscopic versus open hernia repair,” “contralateral patency,” “complications,” “recurrence,” and
Operative time
Of the 90 studies, 38 included in this article reported operative time. The operative time showed very wide variations, depending on the technique and surgical team experience. The average operative time for the repair of unilateral inguinal hernia was 30.1 min via the open approach and 23.7 min via laparoscopy, with no significant difference between the 2 techniques (P = .33). Bilateral hernia repair was significantly longer for the open technique (46.1 min) compared to laparoscopy (30.9 min) (P =
Discussion
In the last 2 decades, the advent of minimally invasive surgery has completely changed the management of pediatric inguinal hernias.4, 15 Analysis of the international literature demonstrates ongoing discussion about the best management of an inguinal hernia in children.14 An interesting finding is that most studies published in the last 20 years have focused on the laparoscopic approach. Conversely, the literature regarding open treatment of inguinal hernia repair is scanty and the real
Summary
Analyzing the international literature, LH appears to require shorter operative times for bilateral hernia repair than the open inguinal crease approach. Recurrence rates appear similar, but the follow-up is shorter in the LH studies. Wound infection appears more likely after OH, but the incidence is low. Time to resume normal activity is similar with both approaches. Further prospective investigations, including long-term follow-up, will be needed to accurately identify the optimal approach
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