Introduction
Inguinal hernia in kids is among the most typical circumstances confronted by pediatric surgeons in on a regular basis apply. It’s estimated that the opportunity of prevalence of inguinal hernia is 0.8–4.4% of the whole variety of kids.1 Nearly all of kids report congenital indirect inguinal hernia.
Although inguinal hernia restore is among the mostly carried out procedures in pediatric surgical procedure, there’s nonetheless a scarcity of consensus on which method: laparoscopic or open, is superior. There are many technical variations of laparoscopic hernia restore, which differ of their outcomes. The laparoscopic method comes with apparent benefits like higher visualization of the inguinal canal, higher cosmesis, sooner restoration, and the power to detect contralateral patent processus vaginalis. There are fewer technical variations in open inguinal hernia restore, and their outcomes differ considerably. Regardless of the described advantages of the laparoscopic method, open inguinal hernia restore remains to be preferable in most pediatric surgical procedure facilities.
There have been a number of systematic opinions printed evaluating laparoscopic versus open restore. Nonetheless, a restricted variety of research present degree 1a proof, and lots of end result parameters haven’t been addressed. In consequence, the talk about one of the best therapy methods remains to be ongoing.2–6
One of the vital generally used laparoscopic approaches in Poland is the percutaneous inner ring suturing method (PIRS) proposed by Patkowski in 2006.7,8 Our evaluation addresses parameters that make this method superior to traditional strategies utilized in inguinal hernia restore in kids.
Supplies and Strategies
Research Design
All sufferers presenting with a grievance of inguinal hernia had been interviewed for the medical signs and examined. The examination included a bodily examination, and belly and inguinal ultrasonography, which neither confirmed nor excluded the opportunity of hernia’s prevalence. An skilled surgeon was proposing surgical therapy in circumstances with evident inguinal hernia. In circumstances with inconclusive prognosis and robust guardians’ need to go for the surgical procedure, the laparoscopic method was suggested. Equally, sufferers identified with bilateral hernia had been provided a laparoscopic methodology.
Guardians had been knowledgeable concerning the proposed sort of therapy by the surgeon who was going to carry out the inguinal hernia restore. The staff consisted of 1 skilled surgeon working with the PIRS method and eleven skilled surgeons working with the open method. Guardians’ requests for the popular method had been at all times revered, and in these circumstances, the working surgeon was modified. All surgical procedures had been carried out underneath basic anesthesia with endotracheal intubation.
Description of the Research Group
The examine group included 276 kids handled for an inguinal hernia between Could 2008 and December 2016 within the Division of Pediatric Surgical procedure, Urology, and Traumatology in Kielce (Poland). 200 and forty-seven sufferers had been operated utilizing the laparoscopic PIRS methodology. Twenty-nine sufferers initially deliberate for the laparoscopic methodology underwent conversion resulting from lack of ability to safe the right closure. In circumstances of the huge opening of the inner inguinal ring, the try of closure with 1–2 stitches was taken. When incomplete closure was noticed, the choice of conversion was made so as to create a good closure, moreover guarded by surrounding tissue. The entire PIRS operations had been carried out by one skilled surgeon. The entry to the belly cavity was obtained by the open Hasson method. Nearly all of the sufferers had been operated with the three.5 mm telescope. In circumstances the place the umbilical ring was dilated, the telescope 5 mm was used. In two circumstances of boys over the age of 15, the 3D 10 mm telescope was launched. All laparoscopic hernia repairs had been carried out with a 30° angle view. The CO2 insufflation stress within the peritoneal cavity was maintained at 8 to 12 mmHg relying on the sufferers’ age. The process was carried out as described by Patkowski.7,8 This includes inserting an injection needle with a non-absorbable thread contained in the barrel of the needle via the belly wall into the peritoneal cavity underneath laparoscopic-guided imaginative and prescient. The thread passes underneath the peritoneum across the entrance into the hernia sac by transferring the injection needle. The knot is tightened from the skin and positioned within the subcutaneous area. In 14 circumstances, a further 3.5-mm or 5.0-mm port was positioned in the appropriate decrease belly quadrant, and a supplementary instrument (grasper or dissector) was used. Additional, an inspection of the belly cavity was carried out for different anomalies (evaluation of pelvic organs, bowel, and gonads in circumstances of strangulated hernia). Routinely earlier than the surgical procedure, the bladder was not emptied. If the visibility was compromised, catheterisation of the bladder was carried out in the course of the process. The length of anesthesia and surgical procedure was recorded.
Description of the Management Group
The management group consisted of 274 sufferers operated with the open inguinal restore methodology between January 2013 and December 2014 in our division by different skilled surgeons. All kids had been operated utilizing the identical open methodology, which included dissection of the vas deferens and vessels and ligation of the hernia sac. Moreover, the anterior wall of the inguinal canal was repaired (utilizing modified Girard methodology).
The information on feasibility, length of the procedures, and extra findings had been recorded and in contrast. The side of recurrence charge and contralateral patent processus vaginalis was additionally analyzed for each teams.
The Statistical Evaluation
The kind of analyzed variables was the criterion for choosing analytic strategies. The measures of location (imply, median, quartiles) and the measure of statistical dispersion (commonplace deviation) had been calculated for quantitative variables to match a number of means – common length of surgical procedure (relying on the kind of hernia) – ANOVA take a look at was used. The χ2 take a look at was used to search out the variations between the studied populations. The extent of significance was set at α = 0.05 within the research. The information had been collected in an Excel spreadsheet (Microsoft MS Workplace). Statistical knowledge analyses had been carried out utilizing STATISTICA ver. 13.1 software program (StatSoft).
Outcomes
Sufferers Demographics
The examine consisted of 131 women and 145 boys and (intercourse ratio: 0.9:1) and in management group: 40 women and 234 boys (intercourse ratio: 0.17:1). Operated sufferers had been aged 0–18, with a median age of 4 years 10 months. The youngest affected person was 3-week previous and the oldest 17 years 5 months (Table 1).
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Desk 1 Sufferers’ Demographics |
Preoperative and Intraoperative Prognosis
There have been 317 PIRS procedures carried out in 276 sufferers. All preoperative diagnoses had been in comparison with the intraoperative findings.
The commonest preoperative prognosis within the examine group was the right-sided hernia (n = 165). The left-sided hernia accounted for 82 sufferers and bilateral 29 circumstances.
Through the laparoscopic process, the prognosis was evaluated within the presence of contralateral patent processus vaginalis (CPPV). The prognosis wanted correction in 53 sufferers. The bilateral inguinal hernia charge elevated from 29 to 79 circumstances. The preoperative prognosis of left-sided hernia was not confirmed intraoperatively in 25 out of 82 circumstances. In a complete of seven circumstances, regardless of the preliminary prognosis of unilateral hernia, the inner opening of the inguinal canal was closed. Two women (certainly one of whom was operated on resulting from suspected recurrency after open method) and 5 boys (three of whom had a medical prognosis of bilateral hernia) represented 2.54% of kids operated on for inguinal hernia not confirmed throughout laparoscopy.
There’s a statistically vital distinction between preoperative and intraoperative prognosis within the studied group (p = 0000) (Table 2).
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Desk 2 Preoperative and Intraoperative Prognosis vs Intercourse within the Research and Management Group |
Amongst women with hernias on the one aspect, the contralateral inner inguinal ring was open in 28 circumstances. Prognosis of bilateral inguinal hernia in females is an indicator for screening for Androgen Insensitivity Syndrome, which might be carried out throughout laparoscopic exploration. Different vital adjustments in prognosis consisted of a lower by 16 circumstances in unilateral left-sided inguinal hernia charge in males. A statistically vital distinction in prognosis in each sexes was famous (men and women p = 0000) (Figures 1 and 2).
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Determine 1 Preoperative and intraoperative prognosis vs intercourse (feminine). |
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Determine 2 Preoperative and intraoperative prognosis vs intercourse (male). |
An oblique hernia was identified within the majority of circumstances. In two sufferers, a direct inguinal hernia was famous.
Within the management group, no change in prognosis was famous. There was no destructive exploration reported, and no direct hernia was noticed within the management group. Through the follow-up interval, a metachronous contralateral inguinal hernia developed postoperatively in 16/274 sufferers who underwent unilateral hernia restore.
Working Time
The length of the process was famous and in comparison with open inguinal hernia restore (medical management group). The length of the process was calculated from the cleansing of the surgical website to the dressing of postoperative wounds. Within the case of a one-sided PIRS process, the imply length was 26 minutes 35 seconds (10 minutes – 55 minutes), a bilateral inguinal hernia – 32 minutes 40 seconds (17 minutes – 60 minutes). The open unilateral inguinal hernia restore length was 36 minutes and 10 seconds. The imply anesthesia time was measured from the beginning of intravenous drug administration and placing on an oxygen masks till the affected person’s extubation within the working room. The imply anesthesia time for unilateral hernia handled laparoscopically was 45 minutes 55 seconds, and for bilateral hernia – 51 minutes and 55 seconds. Within the management group, the imply anesthesia time was 43 minutes and 15 seconds. The median time of surgical procedure for bilateral and left-sided hernia equals Me = 30. The median time for prognosis of the right-sided hernia is Me = 25 (Table 3). The operation’s length is statistically vital relying on the kind of hernia identified in the course of the operation (p = 0.000). There was no relation between affected person age and length of the surgical procedure within the examine (r=−0.1371) (Table 4).
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Desk 3 Length of the Laparoscopic Surgical procedure Evaluation |
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Desk 4 Comparability of the Research and the Management Group |
Contralateral Patency
On this examine, there have been 53 circumstances of open deep inguinal rings on the contralateral aspect (contralateral patent processus vaginalis – CPPV). It counted for 23/82 left-side inguinal hernia with proper CPPV and 30/165 right-side hernia with left CPPV. Out of the 25 boys, 11 reported a left-sided CPPV and 14 a right-sided CPPV. In women, there have been 19 circumstances of left-sided CPPV and 9 circumstances of the right-sided CPPV. Within the management group, no CPPV was famous in the course of the process (Table 4).
Recurrence Charge and Metachronous Contralateral Hernia
Recurrence was noticed in 10 sufferers after the laparoscopic surgical procedure, which accounts for 4.04% (10/247) of the whole variety of surgical procedures and three.15% (10/317) of PIRS procedures. 5 of them underwent inguinal hernia restore utilizing the PIRS methodology, two with the open methodology, and the remaining 3 awaits the surgical procedure as a result of lack of the parental consent.
The management group’s recurrence charge was noticed in 5 circumstances (1.82%), and 16 kids (5.84%) required further process as a result of metachronous contralateral inguinal hernia.
Further Findings
Out of 14 kids operated for incarcerated hernia, an unreduced hernia was recognized in 10 circumstances (5%). Through the laparoscopic process, it was attainable to cut back incarcerated organs and assess the organs of the belly and pelvic cavity. Within the laparoscopic group, there have been two women with the strangulated ovary, and one boy reported with testicular ischemia resulting from strangulated better omentum. Within the management group, there have been 20 kids operated as a result of incarcerated hernia. All sufferers had intestinal viability assessed. Not one of the incarcerated gonads required elimination, and subsequent postoperative ultrasonographic examinations reported correct blood flows and no indicators of gonadal atrophy. Within the laparoscopic group, all stomach cavities had been assessed, which was not attainable within the management group.
All-female sufferers with bilateral herniae (45 women) had the presence of the uterus and uterine appendages assessed. Within the examine group, there was a case of a affected person identified with CAIS in the course of the laparoscopic inguinal hernia restore process. This case was additionally described in our authentic collection.9
In 6 circumstances, intestinal pathology was noticed. In 5 kids, there was intestinal malrotation, and one had Meckel diverticulum famous. These kids had been subjected to intense postoperative management, and their dad and mom/authorized guardians had been instructed concerning the attainable penalties of the detected anomalies.
The laparoscopic methodology had a further benefit. For youngsters with an umbilical hernia, the reconstruction of the umbilicus was carried out. In ten circumstances, the umbilical hernia was identified preoperatively. Moreover, in 10 kids, a widened umbilical ring was detected and categorised for the reconstruction.
Comply with Up
The common post-operative follow-up was 70.6 months (5.9 years) for the examine group. The common follow-up for the management group was 67.7 months (5.6 years).
The recurrence incidence after the PIRS process is 2.4 occasions larger than after open restore, though this isn’t statistically vital (OR = 2376; 95% CI: 0.800–7.058; p = 0.119).
The CPPV is identified 4 occasions extra typically throughout laparoscopy, and there’s a statistical significance (OR = 0.3935, 95% CL: 2185–7084; p = 0.000).
Dialogue
Danger of Creating MCH
Clinically identified inguinal hernia might be scheduled for open surgical procedure or utilizing minimally invasive strategies. Laparoscopy provides a transparent view of the buildings contained in the belly and pelvic cavity,10 whereas open inguinal hernia restore permits the exploration of the affected website. Knowledge recommend that it’s attainable to discover the alternative aspect via the deep inguinal ring throughout open restore of groin hernia.11 Though it’s a difficult process, it’s incessantly inconceivable resulting from a full bladder and belly organs. With out the CO2 insufflation into the belly cavity, the process is relatively impractical as a result of angle of the digicam. In our management group, 5% of sufferers required further surgical procedure as a result of growth of metachronous contralateral hernia.
The incidence of metachronous contralateral inguinal hernias was introduced by Wenk et al12 who described and analyzed six research, together with 1669 kids. The general incidence was 6%. It was famous that the chance of metachronous contralateral inguinal hernia growth is considerably better in kids with an preliminary left-sided hernia (8.5% vs 3.3%) and kids with open contralateral processes vaginalis (13.8% vs 3%). Additional danger components embrace feminine gender (8.2% vs 4.1%) and younger age <1 12 months (6.9% vs 4.5%).12 Within the examine carried out by Thomas et al13 in 16.4% (n = 35) of kids contralateral metachronous hernia was discovered. The proper-sided hernias appeared extra incessantly (57.1%).
One other attention-grabbing retrospective examine was introduced by Chin et al concerning second inguinal hernia repairs. It was estimated that the incidence of contralateral metachronous hernia was 9.62%, and the ipsilateral recurrent hernia was 1.23%.14 The incidence of a metachronous contralateral pediatric inguinal hernia is 6.4% in each genders.15
Incidence of CPPV
The incidence of CPPV in accordance with the literature ranges from 4% to 40%.2–27 In examine group 19% of kids had CPPV handled. Esposito et al, in his examine, famous that 41% (n = 533) of sufferers present process unilateral laparoscopic inguinal hernia restore had CPPV.27 Erginel et al introduced a examine on 205 inguinal hernia repairs in 148 women. It was famous that preoperative prognosis consisted of 51.3% right-sided hernia, 27.7% left-sided and 20.9% bilateral hernia. Nonetheless, in 26 women, the CPPV was visualised in the course of the laparoscopic process and repaired with the PIRS methodology. In whole 38.5% (n = 57) women had bilateral hernias.19
Incidence of Damaging Exploration
Laparoscopy additionally permits to detect sufferers with false-positive inguinal hernia and to typically keep away from an pointless in depth exploration of the inguinal canal on this group of sufferers.28 Different authors have analyzed the issue of the attainable prevalence of metachronous inguinal hernia. Regardless of a real destructive analysis by laparoscopy, there was a 0.8% probability of creating a metachronous contralateral inguinal hernia. Watanabe et al reported that of the 992 sufferers with destructive CPPV at preliminary operation, eight kids (7 boys and one lady) had metachronous contralateral inguinal hernia after the primary operation. This phenomenon is male-oriented and could also be acquired by oblique inguinal hernia with out previous open contralateral processus vaginalis.16
Danger of Improvement of Symptomatic Hernia from PPV
The query for additional evaluation is whether or not a patent processus vaginalis or clinically silent contralateral hernia could develop right into a symptomatic hernia. Some anatomical abnormalities of the inguinal canal could not manifest themselves in the course of the childhood interval. Often, kids aged 10–14 years are introduced for hernia restore with lively signs for a number of weeks or months.17,24
Plainly laparoscopic closure of open inner inguinal ring brings the advantages of avoiding future surgical procedure. Through the laparoscopic process, the kind of hernia could also be outlined, as direct, oblique (indirect), and double hernia. Esposito et al reported that 97.9% of sufferers had an indirect exterior hernia, 1.6% (n = 21) of circumstances had a direct hernia, and a double hernia on the identical aspect (hernia en pantalon) was famous in 0.5% (n = 6).27 Schier F. analyzed 542 kids and located that almost all had been congenital indirect hernias (93%), adopted by direct hernias – 10 circumstances (2.3%), femoral – 4 circumstances (1%), hernia en pantalon – 3 circumstances, and the mixture of femoral hernia and indirect inguinal hernia in a single youngster.23
Danger of Recurrence
One other side mentioned when it comes to inguinal hernia restore is the chance of recurrence.29–31 The recurrence incidence, confused by quite a few authors, is simply barely larger after the laparoscopic therapy than after the normal, open surgical procedure.10,18,23,29,32 Nonetheless, there are authors who, over an extended interval of commentary, didn’t report any recurrence of hernia after the laparoscopic surgical procedure.22,25 It also needs to be emphasised that the laparoscopic methodology, such because the PIRS method, requires a lot much less intervention within the inguinal canal than the normal methodology. Often, it’s simpler to deal with hernia laparoscopically within the case of hernia recurrence after the open surgical procedure. On the similar time, within the case of open surgical procedure of the recurrent hernia beforehand handled laparoscopically, there’s nearly a “pristine” working subject with no disturbances of anatomical buildings resulting from adhesions. Such conditions had been noticed in our examine. One lady was efficiently operated on laparoscopically after two conventional surgical procedures of left-sided inguinal hernia (main surgical procedure and recurrence). On the similar time, there have been sufferers with recurrent hernia handled with the PIRS methodology who, within the case of recurrence, didn’t give their consent for laparoscopic surgical procedure and had been operated with an open method. In such circumstances, surgeons of their working studies stress the truth that the working subject was as unchanged as if the affected person was operated on for the primary time. The variety of recurrences after surgical procedure and the necessity to re-do surgical procedure doesn’t steadiness the necessity to function the sufferers after the metachronous prevalence of inguinal hernia in kids operated historically.29
Evaluation of Incarcerated Organs
One other benefit in kids operated on resulting from inguinal hernia, particularly after its incarceration and discharge, is the evaluation of ovaries, testes, intestines, and different buildings current within the hernia sac. Throughout surgical procedure, ovaries had been present in 3 sufferers, tuba uterine in 2 sufferers, and in a single affected person, the omentum was sliding into hernia sacs.19 Esposito et al discovered an incarcerated hernia in 27 circumstances (2%).27 In one other examine, the identical writer noticed 46 kids with incarcerated inguinal hernias (7.6% of all procedures as a result of presence of inguinal hernia). Twenty-one of 46 kids had been diminished preoperatively after which operated laparoscopically, 25/46 had been irreducible, and so they operated immediately in laparoscopy. Within the first group, the operation time was 23 minutes, and the second group was half-hour. There was one recurrence of hernia in each teams, whereas the scientific literature exhibits the recurrence incidence in such a state of affairs at 15–20%.33 Houben et al reported a 1.6% (n = 34) incidence of irreducible inguinal hernia after discount makes an attempt by the attending surgeon. The bulk (70%) had been seen on the appropriate aspect. The laparoscopic methodology was utilized in 24 sufferers. The content material of incarcerated hernia consisted of intestines (21 circumstances), omentum (4 sufferers). Three women had incarcerated ovaries. Following incarceration, 4 kids required a resection of the necrotic gut, one ovary was eliminated, and one boy was operated on resulting from testicular atrophy (6 months after the primary surgical procedure).34
Further Findings
One other benefit of the laparoscopic therapy of inguinal hernia is the chance to detect different defects within the pelvis and stomach. It additionally permits the inspection of feminine reproductive organs, akin to ovaries, fallopian tubes, and uterus.28,35 In our materials, we noticed the whole androgen insensitivity syndrome (CAIS),36 the place male gonads moved to inguinal canals on each side in phenotypically 4-year-old lady.21,23 In laparoscopy, it’s attainable to look at the issues within the bowel motion, decide the presence of the Meckel’s diverticulum (an identical case was mentioned by Quail et al)37 and to evaluate the place of the appendix. One other side of laparoscopic surgical procedure is the reconstruction of the navel after eradicating the port – this avoids therapy of the umbilical hernia. An integral a part of any laparoscopy is the closure of a gap after the elimination of an umbilical trocar. Laparoscopic surgical procedure damages the nerves across the inguinal canal to a lesser extent than the open surgical procedure. The PIRS process was discovered to be secure and simply relevant and triggered no injury to the ilioinguinal nerve.38
The affected person must be appropriately ready for every laparoscopic process, and their urinary bladder must be emptied. Payiziwula et al reported in early postoperative time a sliding hernia not acknowledged throughout laparoscopic inguinal hernia restore (bladder herniating into the appropriate inguinal area, according to an extraperitoneal invisible, undetectable hernia).35
The therapy of sliding hernia was mentioned by Ishii et al, who within the years 2006–2015, operated 482 women, 14 of whom had invisible inguinal hernia identified preoperatively.39
Feasibility of the PIRS Technique
The simplicity of the PIRS methodology permits it for use throughout different surgical procedures finished laparoscopically. In our materials, there have been two circumstances of inguinal hernia restore carried out throughout laparoscopy for non-complicated appendicitis. Erginel et al made comparable observations. There have been two circumstances of inguinal hernia restore throughout appendectomy and one throughout laparoscopic splenectomy.19 The identical examine discusses an apparent good thing about utilizing laparoscopy for different causes – we will consider the diploma of the inguinal canal restore after the earlier therapy of inguinal hernia carried out each brazenly and laparoscopically. Closed inner inguinal rings had been noticed in a second-look laparoscopy in 2 sufferers as a suspected recurrent hernia after PIRS procedures.19 Related observations had been made in our earlier materials.9,11 One other benefit of laparoscopic strategies over the normal ones is shorter operative and anesthesia time and sooner restoration time.19,40 Most authors stress the aesthetic side of the laparoscopic methodology, with minimal or invisible scars after the surgical procedure.20,21,23 Because of its simplicity and the chance to restore different anomalies, laparoscopy has a bonus over conventional strategies and may grow to be a way of alternative for an skilled surgeon within the therapy of inguinal hernia in kids, particularly in women.7,8,13,19–21,25–27,39
Conclusions
The laparoscopic method to inguinal hernia restore is possible as it’s related to a considerably shorter length of surgical procedure and anesthesia. It permits making a correct prognosis with detection and closure of CPPV. Laparoscopy additionally brings the opportunity of inspection of belly and pelvic organs and evaluation after incarceration.
Institutional Evaluation Board Assertion
The examine was carried out in accordance with the rules of the Declaration of Helsinki, and authorised by the Institutional Analysis Committee of Jan Kochanowski College Analysis Ethics Board, nr 12/2016.
Knowledgeable Consent Assertion
Knowledgeable consent was obtained from all topics concerned within the examine. The guardian or authorized guardian of every youngster supplied knowledgeable consent.
Funding
This work was supported underneath this system of the Minister of Science and Greater Schooling underneath the identify Regional Initiative of Excellence in 2019–2022 undertaking quantity: 024/RID/2018/19, financing quantity: 11.999.000.00 PLN.
Disclosure
The authors declare no conflicts of curiosity on this work.
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