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Author's Accepted Manuscript

Current concepts in the management of


inguinal hernia and Hydrocele in pediatric
patients in laparoscopic era
Ciro Esposito MD, PhD, Maria Escolino
Francesco Turr MD, Agnese Roberti
Mariapina Cerulo MD, Alessandra Farina
Simona Caiazzo MD, Giuseppe Cortese
Giuseppe Servillo MD, Alessandro Settimi

MD,
MD,
MD,
MD,
MD
www.elsevier.com/locate/sempedsurg

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DOI:
Reference:

S1055-8586(16)30019-1
http://dx.doi.org/10.1053/j.sempedsurg.2016.05.006
YSPSU50631

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Seminars in Pediatric Surgery

Cite this article as: Ciro Esposito MD, PhD, Maria Escolino MD, Francesco Turr
MD, Agnese Roberti MD, Mariapina Cerulo MD, Alessandra Farina MD, Simona
Caiazzo MD, Giuseppe Cortese MD, Giuseppe Servillo MD, Alessandro Settimi
MD, Current concepts in the management of inguinal hernia and Hydrocele in
pediatric patients in laparoscopic era, Seminars in Pediatric Surgery, http://dx.doi.
org/10.1053/j.sempedsurg.2016.05.006
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#7
Current concepts in the management of inguinal hernia and hydrocele in pediatric patients in
laparoscopic era
Ciro Esposito, MD, PhD1, Maria Escolino, MD1, Francesco Turr, MD1, Agnese Roberti, MD1,
Mariapina Cerulo, MD1, Alessandra Farina, MD1, Simona Caiazzo, MD2, Giuseppe Cortese, MD2,
Giuseppe Servillo, MD2, Alessandro Settimi, MD1
1

Pediatric Surgery Unit, Department of Translational Medical Sciences, Federico II University, Via

Pansini 5, 80131, Naples Italy


2

Pediatric Anesthesiology Unit, Department of Anesthesiology, Federico II University, Via Pansini

5, 80131, Naples Italy

Corresponding Author:
Prof. Ciro Esposito
Full Professor of Pediatric Surgery
Federico II University of Naples
Via Pansini 5, 80131 Naples, Italy
Tel: + 39 081 746 33 78
Fax: + 39 081 746 33 61
E-mail: ciroespo@unina.it

Abstract
The surgical repair of inguinal hernia and hydrocele is one of the most common operations
performed in pediatric surgery practice. This paper reviews current concepts in the management of
inguinal hernia and hydrocele based on the recent literature and the authors experience. We
describe the principles of clinical assessment and anesthetic management of children undergoing
repair of inguinal hernia, underlining the differences between an inguinal approach and minimally
invasive surgery (MIS). Other points discussed include the current management of particular
aspects of these pathologies such as bilateral hernias; contralateral patency of the peritoneal
processus vaginalis; hernias in premature infants; direct, femoral and other rare hernias; and the
management of incarcerated or recurrent hernias. In addition, the authors discuss the role of
laparoscopy in the surgical treatment of an inguinal hernia and hydrocele, emphasizing that the
current use of MIS in pediatric patients has completely changed the management of pediatric
inguinal hernias.

Key Words: Inguinal hernia, hydrocele, children, laparoscopy, pediatric patients

Introduction
A surgical intervention for inguinal hernia (IH) and hydrocele is one of the most common
operations performed in children1. Inguinal hernia and hydrocele have a common etiology,2 and the
surgical correction of both pathologies is similar3. 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% to 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
increases to approximately 30% in infancy7.

Bilateral inguinal hernia is significantly more common in younger patients with an incidence of
about 50% in children under one year of age 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 repair8,9. In the pediatric population, the traditional inguinal approach is an
excellent method for hernia repair10. 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 hernia11,12.

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 ring4,14. In 1998, Schier introduced his technique, consisting of an N-shaped suture
on the peri-orificial peritoneum13. In 2004, Becmeur and coworkers16 described laparoscopic
3

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 techniques17.

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 Esposito18, 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, 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
anaesthesia14. The indications for, and contraindications to LH are controversial and the superiority
of LH versus OH continues to be debated19,20. This review aims to evaluate current concepts in the
management of inguinal hernia and hydrocele in an era of minimally invasive surgery.

Diagnosis
The diagnosis of inguinal hernia is clinical. In general, patients with hernia are adequately assessed
by history and physical examination1. 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
incarcerated at the time of examination, a mass is usually palpated in the inguinal region22 (Fig.1).
4

In girls, a small mobile mass often appears in the groin or labia, which usually represents an
ovary23. The differential diagnosis of hernia from a hydrocele is important. In case of hydrocele
there is a painless swelling within the scrotum. It is larger in the evening than in the morning.
Clinical examination reveals a fluctuant painless swelling, which may or may not be reducible.
Transillumination reveals a fluid-filled scrotum which may be bilateral, particularly in infants24
(Fig.2).
Anesthesia
The majority of infants and children undergoing surgical treatment of hydrocele and hernia require
pre-anesthetic medication and general anesthesia25. 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 mg to 1.0 mg/kg.
Upon arrival to the operating room pulse oximetry, heart rate, and non-invasive arterial blood
pressure are monitored. Anesthesia is induced with sevoflurane 8% in oxygen 6 L/min via face
mask. Sevoflurane is currently one of the volatile agents of choice in pediatric anesthesia for
inhalation induction. It is suitable because it has a pleasant smell, does not irritate the airways and
its blood-gas partition coefficient is slightly greater than that of desflurane or nitrous oxide.
Vascular access is obtained (22 or 24-gauge IV) after loss of the eyelash reflex, and opioid is given
to maintain a suitable depth of anesthesia.

Airway management using a laryngeal mask or endotracheal tube are both acceptable alternatives26.
The relative ease of insertion and lower rate of airway complications compared to endotracheal
intubation makes laryngeal mask use a logical choice, but an endotracheal tube is the safest strategy
for the patient with a full stomach, an irreducible inguinal hernia, and for laparoscopic surgery.

Anesthetics produce dose-dependent and drug-specific changes in respiratory mechanics and in the
central control of the respiratory centre. Inhaled anesthetics decrease muscle tone within the
airways, chest wall and diaphragm, in addition to inhibiting central respiratory drive and
responsiveness to ventilatory stimulants such as carbon dioxide. Intravenous anesthetics may also
alter respiratory function, while opioids produce a dose-dependent depression of medullary
respiratory centers, also resulting in decreased responsiveness to partial pressure of carbon dioxide
(PaCO2). For these reasons, regional anesthesia is often used in combination with general
anesthesia for pediatric surgery and has been shown to reduce general anesthetic requirements,
opioid use, postoperative nausea and vomiting and pain27-28.

Pain is a major concern in patient recovery. By providing optimal pain management, providers can
improve patient and parent satisfaction, mobility, compliance, hemodynamic alterations from stress
responses, and potentially even wound healing. Regional anesthesia is often used to supplement
general anesthesia and provide postoperative analgesia. The most common forms used are regional
nerve block or caudal anesthesia performed after the induction of general anesthesia29. Local
anesthetic for regional nerve block after herniorrhaphy is introduced at a puncture site 1 cm medial
to the anterior superior iliac spine. Because the nerves most commonly run below the external
oblique, the needle is advanced until a click is felt as the needle passes through the external
oblique and the local anesthetic is injected. Caudal block is performed by injecting local anesthetic
into the epidural space via the sacral hiatus. Standard dosing provides neuraxial blockade of sensory
input at and below the T10/umbilical dermatome30.

Finally, the intranasal use of clonidine is interesting31. Clonidine acts as an agonist at alpha-2
adrenoceptors. The locus ceruleus (LC) is the site of action for the sedative effect of clonidine. The
LC contains a high density of alpha-2 adrenoceptors. Following binding of clonidine to alpha-2
adrenoceptors, hyperpolarization of noradrenergic signaling to the ventro-lateral preoptic area
6

(VLPO) occurs, producing sedation. The drug is rapidly absorbed by the nasal route, and peak
plasma levels are reached within 10 min. No sign of irritation or edema in the nasal cavity has been
observed after a single dose. Intranasal administration of drugs is an easy and minimally invasive
alternative route of administration: a relatively large surface area is available for drug absorption
and a thin, very vascularized epithelium ensures rapid absorption and onset of therapeutic action by
avoiding the first-pass effect.

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 the basis of our ESPES program, MIS training for pediatric surgeons must contain the
following educational components: (1) theoretical knowledge; (2) practice-based learning and
improvement in an experimental setting; initially on pelvic trainers and then on live animal models;
(3) training in European centers of reference for MIS; and (4) personal operative experience. At the
end of the training program, ESPES will analyze the candidates training booklet and provide each
applicant with ESPES certification after an exam. This training program has not been officially
adopted in Europe, but there are strong recommendations to follow it, in order to protect pediatric
surgeons from a medico-legal point of view in case of complications following a laparoscopic
procedure32,33.

Indications for surgery


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 infants discharge from
the neonatal intensive care unit34. Infants under the age of 6 months are usually booked on a soonavailable operating list. Older children with few symptoms can be booked electively35,36.
Surgical treatment is offered for inguinal hernia to prevent the complications of incarceration and
obstruction, potentially resulting in vascular insufficiency of the hernia contents (usually a loop of
intestine) as well as surrounding cord structures. In females, torsion/ischemia of the ovary is also
possible37,38.
Hydrocele
Surgical indications for hydrocele are mostly age-dependent. Most surgeons advocate observation
of hydroceles in infants less than 24 months of age. Others may continue observation for longer, as
the majority of PVDs (peritoneo-vaginal ducts) will close within the first 24-36 months of life39.

Timing of surgery
As mentioned, infants under the age of 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 analgesia and/or sedation.
Reduction may spontaneously occur prior to a manual attempt if the infants buttocks are elevated
slightly to assist in the reduction of hernia contents. The hernia is palpated distally while the
clinicians fingers are placed at the proximal neck of the hernia. Compression of the hernia can then
occur. The pressure is maintained slowly and consistently until the hernia is reduced 41. Incarcerated
hernias that are reduced have an incidence of reincarceration as high as 15% if definitive repair is
delayed more than 5 days42. If a hernia cannot be completely reduced, an operative approach is
indicated to reduce the hernia, inspect the integrity of the contents, and to ligate the hernia sac.
Operative positioning
In open inguinal repair the surgeons 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.
Open inguinal approach
The open technique of inguinal hernia repair requires an inguinal approach. A 3-4 cm long inguinal
incision is made on the side ipsilateral to the symptomatic inguinal hernia. The procedure involves
the separation of the hernia sac from the surrounding cord structures, including cremasteric muscle,
9

vas deferens, and the testicular vessels or round ligament (Fig. 3). A ligature is applied to the
proximal separated sac, and the distal sac is divided. There is no evidence in the literature favoring
absorbable versus non-absorbable suture. Historically, during the open repair of a unilateral inguinal
hernia, contralateral patency of the processus vaginalis was not assessed. In the 1980's, French
pediatric surgeons described a technique to identify a contralateral processus vaginalis or hernia,
consisting of the passage of a 45 or 70-degree angled telescope through the hernia sac prior to
ligation (hernioscopy)43. This technique requires the creation of pneumoperitoneum and use of the
full range of laparoscopic equipment; for this reason, it is infrequent (in our experience) in clinical
practice.

The treatment of hydrocele requires the same surgical procedure described for open inguinal
herniotomy. In older children a scrotal approach may be adopted. In case of communicating
hydrocele, an inguinal incision is performed, the PVD is ligated and sectioned, and an attempt is
made to empty the distal fluid, if not already drained. This often requires an incision distally, down
to the scrotal tunica vaginalis, to release any residual fluid 39.

Laparoscopic technique
The laparoscopic approach can be performed either transperitoneally or through a pre-peritoneal
approach (using special needles) with transperitoneal visualization20. The transperitoneal
laparoscopic approach uses 3 ports11 and a 0 degree, 5 or10 mm telescope is inserted through the
umbilical port, allowing direct visualization of the internal inguinal rings. Two 3-mm trocars are
inserted in triangulation for good ergonomics. 5 or 10-mm optics both result in a nearly invisible
umbilical scar; selection of one over the other depends on the instruments available or surgeon
preference. Most authors prefer 3-mm screw trocars, particularly in infants < 10 kg in whom the
10

skin and underlying tissues are very thin. Smooth trocars can be easily displaced in these children,
creating subcutaneous emphysema. Screw trocars are more stable and enable rapid change of
instruments without dislodgement and gas leaks (Fig. 4). If the only trocar available is of the
smooth variety, a piece of Nelaton catheter may be placed around the cannula, with suture fixation
of the catheter to the skin to stabilize the trocar (Fig. 4). Some surgeons prefer to use instruments
without the assistance of trocars (via stab incisions), but this technique may make instrument
change difficult.

The laparoscopic technique affords confirmation of the diagnosis, as well as inspection of the
contralateral side for the presence of a hernia or a contralateral patent peritoneal vaginalis duct
(CPVD). For intracorporeal hernia ligation, the needle has to be introduced into the abdominal
cavity trans-parietally and then removed trans-parietally or trans-umbilically. Our preferred needle
is 3/8 of a circle with a 20-22 mm needle. To perform a unilateral closure, the length of suture is 1315 cm; for a bilateral repair we use 15-20 cm long suture, but this may vary according to the
surgeons preference. After sectioning the peri-orificial peritoneum, the internal inguinal ring is
then closed, either with absorbable or permanent suture. A purse string suture as described by
Montupet (Fig. 5), or an N- suture as described by Schier4 can be used. These two techniques
seem to yield similar long term outcomes in the literature4. A peritoneal flap closure is an
alternative technique using this access method.

In the pre-peritoneal (needlescopic) approach, a small hook loaded with a suture is passed around
the deep ring after making a very small inguinal skin incision. The passage of the suture is observed
via an endoscope via the umbilicus. The ligature is then brought out extracorporeally and tied, thus
closing the hernia orifice43,44.

11

Currently, the open inguinal approach remains the preferred technique to treat hydrocele. However,
with communicating hydroceles a laparoscopic repair can be considered. The technique is similar to
the laparoscopic repair described above for inguinal hernia; the fluid is aspirated and the PVD is
closed with a purse string suture at the level of internal inguinal ring.

Laparoscopy has several advantages over open surgery in the treatment of inguinal hernia. There is
a reduction of skin infections, particularly in infants45,46 in whom the inguinal incision is inside the
diaper with a higher risk of infection, while laparoscopic incisions are outside the diaper area.
Perhaps the primary advantage of laparoscopy is to identify and to treat a contralateral patency of
PVD, present in about 50% of patients, but increased in younger patients 47.

Laparoscopy also facilitates the identification and treatment of other types of hernia, such as direct,
femoral, and double hernias ("hernia en pantalon").45 A key point of the laparoscopic repair of a
direct inguinal hernia is to remove the lipoma (always present in this pathology) and to close the
defect using a purse string suture or separated stitches. In the case of large defect, the lateral bladder
ligament can be used to reinforce the closure.48,49

In addition, laparoscopy is considered the gold standard in the management of recurrent hernia after
an open repair, allowing for identification and treatment of the cause of the recurrence50.
Laparoscopy is also superior to open inguinal hernia repair in small infants, as well as for the
incarcerated hernia. Reduction of the incarcerated bowl via laparoscopy is easier to accomplish and
concomitant evaluation of bowel viability is possible51,52.

12

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 key words were used: inguinal
hernia, herniorrhaphy, hernia repair, children, laparoscopic versus open
herniorrhaphy, laparoscopic versus open hernia repair, contralateral patency,
complications, recurrence, and hydrocele. Searches were also performed using the
following limits: clinical trials, randomized controlled trials, multicenter retrospective, prospective
studies, and expert opinion. Conference abstracts were excluded because of the limited data
presented in them. Publications with evidence of possible overlap were also excluded from this
review. Although no language restrictions were imposed initially, the search was limited to studies
published in the English language for the full-text review and final analysis. Eligibility criteria
included all available studies focused on LH and/or OH and with quantitative data on outcome
parameters. The pediatric population was defined as younger than 18 years when the patient
underwent LH or OH. After relevant titles were identified, the abstracts of these studies were read
to decide if the study was eligible. The full article was retrieved when the information in the title
and/or abstract appeared to meet the objective of our review. The authors independently assessed
selected studies and tabulated data from each article with a predefined data extraction form. Data
regarding the following factors were considered: first author, publication date, study method,
participant features, intervention characteristics, definition of complications, and outcome
measures. Outcome parameters for inclusion were patients age, gender, affected side, operative
time, time to resume full activity, duration of hospital stay, recurrence, metachronous contralateral
hernia, and complications. We identified 203 studies, but 113 of these were excluded from our
analysis using the following criteria: studies in which the outcomes of interest were not reported for
one of the two techniques, or it was impossible to calculate these from the published results; studies
13

that were not focused on a pediatric population; and studies reporting modifications of the standard
laparoscopic techniques. The chi-squared or Fishers exact test was used to evaluate the significance
of differences between the two groups, LH and OH.
Results
Operative time
Thirty-eight of the 90 studies included in this review 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 minutes via the open
approach and 23.7 minutes via laparoscopy, with no significant difference between the two
techniques (P = .33). Bilateral hernia repair was significantly longer for the open technique (46.1
minutes) compared to laparoscopy (30.9 minutes) (P = .01). A conversion rate was reported in 10
studies and ranged between 0% and 1.7%, but in the majority of these studies there were no
conversions at all13,18,41,42,50,58,63. There is no data in the literature comparing operative time of
hydrocele repair using open versus laparoscopic approaches (Table 1).

Postoperative recurrence and other complications


Reported complications include recurrence, hydrocele, wound infection, iatrogenic cryptorchidism,
testicular atrophy, and injury to the spermatic cord elements. Recurrence rate for OH ranged from
0% to 6%, and LH recurrences ranged from 0% to 5.5%. Looking at the averages, there was no
significant difference regarding reported recurrence rates between the two techniques (P = .66).
Analyzing the results for infants only, the recurrence and wound infection rates seem to be higher
after OH compared to LH 45,73,76.

14

Other complications, such as wound infection, hydrocele, iatrogenic cryptorchidism, and testicular
atrophy, were significantly higher for OH (2.7%) compared to LH (0.9%) (P = .001). In particular,
some articles reported that the incidence of complications such as cryptorchidism and testicular
atrophy was always higher after OH than after LH (P = .001) 43,54,71,76,77.

Rare hernias
Many uncommon hernias were identified in the LH studies, with an incidence ranging from 0.3% to
7.2% 5,11,16,52,62,70,78,79. The most common hernia in this category was a direct hernia (81.5%),
followed by femoral hernia (10%), hernia en pantalon (4.3%), and a combination of indirect
hernia with femoral hernia (1.4%), indirect hernia with direct and femoral hernia (1.4%,), and
Amyands/Littres hernia (1.4%) (Table 2). No rare hernias were reported in the literature for OH
patients.
Contralateral pathology
Twenty-seven studies reported the coexistence of a unilateral inguinal hernia, with a contralateral
patent peritoneal vaginal duct (CPVD), for an incidence of contralateral patency between 19.9%
and 66%. It is interesting to note that the highest occurrence of CPVD was reported in the smaller
infants73,87 (Table 2).

Discussion
In the last two decades, the advent of minimally invasive surgery has completely changed the
management of pediatric inguinal hernias4,15. Analysis of the international literature demonstrates
ongoing discussion about the best management of an inguinal hernia in children14. 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
15

the real incidence of complications after inguinal hernia repair is probably underestimated. There
are also few reports in the literature specifically targeting hydrocele repair, although it appears that
the classic treatment of hydrocele using an inguinal approach still represents the standard of care39.

Our review examined the efficacy and safety of the laparoscopic approach compared with the
inguinal approach in the management of inguinal hernia in children. The results of this review in
regard to operative time suggested that there was no significant difference between the two
approaches for unilateral inguinal hernias (P = .33). However, in patients with a bilateral hernia,
there was a significant reduction in the operative time for LH compared with OH (P = .01). The
operative time did show wide variation, depending on the technique and experience of the surgical
team. No significant differences were observed for recurrence rates between the two techniques (P
= .66); whereas the rates of other complications such as wound infection, hydrocele, iatrogenic
cryptorchidism, and testicular atrophy were significantly higher for OH compared to LH (P = .001).
In addition, recurrence rate and wound infections in infants were always higher after OH than after
LH 45,73,76. In our opinion, the higher wound infection rate following OH may be due to the fact that
laparoscopic incisions are located higher on the abdominal wall than inguinal incisions, which are
inside the diaper area; for this reason, they are subject to urine or fecal contamination, which may
lead to a higher infection rate. In fact, studies on LH reported fewer wound infections compared
with infants of similar age operated through the inguinal approach (0% for Esposito et al.45 versus
2.3% for Nagraj et al.76).

Complications after OH (vas deferens injuries, iatrogenic cryptorchidism, testicular atrophy) have
been rarely reported in the last 1520 years. For this reason, we had to analyze older published
series to obtain adequate data for comparison purposes. We found five studies that reported an
incidence of postoperative cryptorchidism and testicular atrophy that was higher after OH than LH
(P = .001) 43,54,71,76,77. Accurate comparisons between the two approaches for these complications
16

suffer from the use of historical controls. There also was a shorter follow-up in the LH series
compared to the OH studies.

The advantages of LH are believed to include better visualization of vital cord structures, which
makes dissection of these structures safer. The dissection field of LH is limited to the peritoneal
layer, with the vas deferens and cord left untouched. Therefore, injury to the vas is not thought to
occur very often 63. This review also reinforces the usefulness of the laparoscopic approach for the
diagnosis of contralateral patency, which may avoid the need for a second surgery and anesthesic in
patients with a metachronous contralateral hernia. It is our feeling that repair of a CPVD should be
offered to all families, since most desire to have the CPVD repaired at the same operative setting
when this option is offered70,88.

A meta-analysis by Miltenburg et al.6 showed that laparoscopy has a sensitivity of 99.4% and a
specificity of 99.5% (regardless of patient age, gender, or side of presentation) in detection of
CPVD and other various forms of hernia. In particular, laparoscopy provides a clearer view to
identify uncommon hernias such as a direct, femoral, or hernia en pantalon, allowing the
appropriate operative technique. Zendejas et al.89 found that the factor most significantly associated
with an increased risk of recurrence was a direct hernia: the most common cause of recurrent
inguinal OH is a direct hernia not recognized at the time of initial repair. Laparoscopy should
eliminate this issue. As reported by Esposito et al.48 and Lima et al.49, it is extremely easy to
identify a direct hernia during laparoscopy. In laparoscopic direct inguinal hernia repair, it is
important to identify and resect the hernia lipoma (always present); then the surgeon closes the
hernia defect, with the aid of the bladder lateral ligament to reinforce the repair. Another advantage
of laparoscopy may be in the management of incarcerated hernias, especially in infants 51,52.

17

From a technical point of view, the laparoscopic approach is easier but at the same time technically
more demanding for the surgeon, since he or she has to be able to work in a very small space
because of the bowel distension. Therefore, it is often useful to perform one or two enemas the day
before operation and to use simethicone to empty the intestinal loops of gas, both of which allow
the creation of a larger working space in the abdominal cavity 90. In small infants, true triangulation
between the optical port and the working instruments is difficult because the two operative cannulas
are located higher than their usual position; we prefer to position the ports at the same level as the
optical cannula to create more distance between the ports and the internal inguinal ring. By adding
these technical refinements, LH has become an easy approach in difficult repairs such as the
neonatal inguinal hernia 45. Recent literature suggests that neonatal inguinal LH is easier and
associated with fewer complications than open inguinal hernia repair76. In two studies, similar time
to full feeds and length of hospital stay were reported in the LH and OH groups73,77. A metaanalysis by Yang et al.74 found that LH was superior to OH in the repair of bilateral pathology with
a lower rate of metachronous contralateral hernia and a similar operative time for unilateral hernias,
and similar length of hospital stay, recurrence, and complication rates. They also found a trend
toward higher recurrence rate for laparoscopic repair. One potential disadvantage of LH that is not
able to be addressed in this review is the fact that a transabdominal operation is performed with LH
when compared with the extraperitoneal approach with the inguinal crease technique. A second
disadvantage may be that the laparoscopic incisions, although small, are visible above the
underwear/ bathing suit line when compared with the inguinal crease incisions. Prospective
randomized trials have not been performed on the cosmetic aspects of either approach.

An open inguinal approach still seems the preferred way to treat patients with hydrocele. One role
for laparoscopy in the treatment of hydrocele might be in a child with a unilateral inguinal hernia
and a contralateral hydrocele. In conclusion, while the inguinal approach remains the technique of

18

choice to treat hydrocele, in case of inguinal hernia laparoscopy seems to be a very good alternative
to open surgery 1,14,43.

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 for inguinal hernia repair in infants and children.

In conclusion, definitive evidence in the literature about which technique (laparoscopy or inguinal
approach) is preferable to repair an inguinal hernia is still lacking. A reasonable approach is to
recognize the importance of the parental role in the decision process, and to offer to the
patient/family both techniques and the advantages and disadvantages of each.

19

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28

Legends
Table 1: Operative time and conversion rate of hernia repair performed via the open or laparoscopic
approach.
Table 2: Incidence of rare hernias and contralateral patent peritoneal vaginal duct (CPVD)
identified during laparoscopic hernia repair.
Figure 1: An incarcerated hernia appears as an irreducible mass in the inguinal region.
Figure 2: Transillumination reveals a fluid-filled scrotum and confirms the diagnosis of hydrocele.
Figure 3: Open inguinal hernia repair requires an inguinal incision and the separation of the hernia
sac from the surrounding cord structures.
Figure 4: Trocars used for laparoscopic hernia repair: a) smooth trocars with a piece of Nelaton
catheter around the cannula to be fixed to the skin to stabilize the trocar; b) screw trocar
Figure 5: Laparoscopic hernia repair according to Montupets technique: a) the peri-orificial
peritoneum is sectioned; b) the needle is introduced transparietally; c) a purse string suture is placed
on the peri-orificial peritoneum; d) the hernia defect is closed.

29

Table 1: Operative time and conversion rate of hernia repair performed via the open or laparoscopic approach

Reference

LH

Gorsler et al 2003 5
Parelkar et al 20107
Esposito et al 2009 11
Schier 2006

12

Schier 1998 13
Becmeur et al 2004

16

18

Montupet 1999

Operative Time
Unilateral LH
(minutes)

Operative Time
Bilateral LH
(minutes)

403

14

21

576

23

29

315

18.5

30.5

712

20

22

18

96

25.5

47

Bharathi et al 2008 19
Alzahem 2011 20
Kaya et al 2006

OH

41

Operative Time
Unilateral OH
(minutes)

Operative Time
Bilateral OH
(minutes)

1-0.25%

0%
35

30

51

34

25.3

1300

1399

10

18

15

39

58

248

0%
30.6
30

14

28

29

Koivusalo et al 2007 42
43

Niyogi et al 2010

0%
29

42.2

37.5

186

13.2

25.6

Esposito et al 2012 45

67

22

Esposito and Montupet


1998 50

225

Chan et al 2005 53

42

44

14.7

20.1

12

26.2

100

57

36

45.5

46

62

Tsai et al 2010

45.1

0%

Shalaby et al 2006 44

54

16

20

Kamaledeen et al 1997 56

24

30

104

41

Usang et al 2008

Shalaby, Desoky 2002 58

169

12.6

14

Chan 2007 59

15.2

35

Chang et al 2008 60

52

31.2

Yamoto et al 2010 61

92

22.4

30.5

62

Schier et al 2002

933

16

23

Oak et al 2004 63

110

25

35

Spurbeck et al 2005 64

120

38

47

Chan et al 2007 65

451

15.7

19.7

Bharathi et al 2008 66

180

25

40

20.8

26.7

18.5

25.5

Dutta, Albanese 2009

67

Lipskar et al 2010 68
Montupet 2011

69

275

Shalaby et al 2012

71

58
0%

0%

1-0.9%

17

241
596

Esposito et al 2012 70

66

0%

Misra et al 1995 55

57

89

11

17.5

3-1.7%

20

125

125

11.1

14.1

17.3

29.1

Yerkes et al 1997

72

627

132

44.8

51.6

42.2

48.3

Saha et al 2013

73

30

32

47.6

57.1

28.7

33.5

1543

657

15

20

19

35

Yang et al 2011 74
Shalaby et al 2007

75

250

Conversion
rate

10

LH- laparoscopic herniorrhaphy; OH- open herniorrhaphy

30

Table 2: Incidence of Rare Hernias and Contralateral Patent Peritoneal Vaginal Duct (CPVD) identified during
Laparoscopic Hernia Repair

Reference

Patients

Rare Hernias

CPVD Incidence
(%)

Gorsler and Schier2003

403

Miltenburg et al 1998 6

11 DH

2.7

45.2

964

38.7

Parelkar et al 2010

576

19.9

Esposito et al 2009

11

315

Schier 1998

13

0.3

22
16

Becmeur et al 2004
Ehsan et al 2009

96

47

54

39
57.1

3 DH

3.1

363
52

Esposito et al 2013
Tsai et al 2010

1 DH

7.3
39.7

1 AH

100

31

Shalaby, Desoky 2002 58

169

7.2

Schier et al 2002 62

933

Oak et al 2004

63
64

Spurbeck et al 2005
Chan et al 2007

65
68

Lipskar et al 2010

Montupet, Esposito 2011

69

70

Esposito et al 2012
Yerkes et al 1998
Saha et al 2013 73
Nah et al 2011

77

Becmeur et al 2007

78

2.3

38

110

24.5

120

33.3

451

39

241

34

596

15.9

89

72

22 DH

2 DH

2.2

44.9

759

42

30

66

63

54

212

3 DH

2.3

2 FH
Schier and Klizaite 2004

79

275

10 DH

7.2

5 FH
3 HP
1 IH+FH
1IH+DH+FH
Holcomb et al 1996 80
Tackett et al 1999
Handa et al 2006

81

82

Steinau et al 2008

83

518

41

656

8.8

171

22.2

368

Kalantari et al 2009

84

301

9.3

Holcomb et al 1996

85

599

46

1603

40.1

284

29.9

Valusek et al 2006

86

Bhatia et al 2004

87

DH- Direct Hernia; FH- Femoral Hernia; IH- Indirect Hernia; HP- Hernia en Pantalon; AH- Amyands Hernia; CPVD Contralateral Patent
Peritoneal Vaginal Duc

31

32

33

34

35

36