The Role of Laparoscopy in Children With Groin Problems

Himanshu Aggarwal; Barry A. Kogan

Disclosures

Transl Androl Urol. 2014;3(4):418-428. 

In This Article

Inguinal Hernia

The basic principle of open inguinal hernia repair in pediatric patients is the ligation of the patent processus vaginalis and this is considered the gold standard for pediatric inguinal hernia repair.[72–74] With the advent of the laparoscopic era, the trend began to move toward the application of laparoscopic techniques for pediatric hernia repair. In laparoscopic hernia repair, after the identification of patent internal ring, the overlying peritoneum is closed with a laparoscopic purse-string suture.[75] The reported recurrence rate for pediatric laparoscopic inguinal hernia repair was approximately 4.4%[76,77] while the recurrence rate for open hernia repair has historically ranged from 0.3% to 2.5%.[73,78,79] In order to improve these results, modifications and technical refinements of laparoscopic repair have been proposed, including placement of the stitch medial to the inferior epigastric artery[80] and the use of special needles or non-absorbable sutures.[81] In addition, there are some very innovative techniques including a completely extraperitoneal laparoscopic repair[73] and laparoscopic hernia repair by the hook method[82] both of which have claimed a very low rate of recurrence in short follow up. Some studies have also reported that laparoscopic hernia repair in pediatric population leads to less pain, quicker recovery and better wound cosmesis. There is also the potential side benefit of simultaneous detection and repair of contralateral patent processus vaginalis.[75,83,84] However the very low morbidity of open pediatric inguinal hernia repair with its proven long-term efficacy and low rate of damage to the vas, suggests that long term follow up studies are needed before laparoscopic hernia repair will replace the open inguinal hernia repair in pediatric patients.[75,84]

Contralateral Patent Processus Vaginalis

Although there is insufficient evidence to recommend the use of laparoscopic inguinal repair over open hernia repair in pediatric patients, the role of diagnostic laparoscopy for detection of contralateral patent processus vaginalis in patients with unilateral inguinal should not be underestimated.[85–88] A meta-analysis reported that diagnostic laparoscopy is 99.4% sensitive and 99.5% specific in identifying the presence of a contralateral patent processus vaginalis.[89] The reported patency rate of a contralateral patent processus vaginalis in patients with unilateral inguinal hernia has ranges widely from 11–74% amongst different studies.[62–68,90] Whether the contralateral groin should be examined is a matter of debate with the authors of many publications taking sides in this debate. The opponents of routine contralateral groin exploration argue that it may lead to overtreatment of patients, as the true incidence of clinically significant contralateral hernia is only 5–29%[91–94] hence they argue that the repair of a contralateral processus vaginalis should not be performed.[95–97] On the other hand, other authors have recommended the routine inspection as well as repair of contralateral patent processus vaginalis, as it is safe, reproducible, technically easy[20,86,98] and cost effective.[99] Also, there are the advantages of avoidance of a second anesthetic, sparing the parents of the anxiety associated with a second operation, and sparing the physician the embarrassment associated with the appearance of a second hernia at a later date.[71] For these above mentioned reasons we routinely inspect and repair contralateral patent processus vaginalis.

The presence of a contralateral patent processus vaginalis in children with unilateral inguinal hernia can be safely and effectively evaluated by CO2 insufflation (Goldstein test),[69] transabdominal laparoscopy[70] or transinguinal laparoscopy.[62,63,71] We prefer transinguinal laparoscopic approach in our center as described above in section of palpable testis.

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