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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
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Year : 2021  |  Volume : 26  |  Issue : 2  |  Page : 107-110

Laparoscopic Inguinal Hernia Repair in Children: To Cut or Not to Cut is the Question?

1 Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Anaesthesiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission04-Feb-2020
Date of Decision22-Mar-2020
Date of Acceptance07-Jul-2020
Date of Web Publication04-Mar-2021

Correspondence Address:
Dr. Kirtikumar J Rathod
All India Institute of Medical Sciences, Jodhpur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9261.310657

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Context: Laparoscopic repair of pediatric inguinal hernia is gaining popularity, however there is no consensus about the technique of operation.
Aims: The aim of the study was to compare the results and complications of two techniques of laparoscopic pediatric hernia repair.
Settings and Design: This retrospective study was conducted at the Department of Pediatric Surgery in All India Institute of Medical Sciences (AIIMS), Jodhpur.
Subjects and Methods: All children who underwent laparoscopic inguinal hernia repair at AIIMS, Jodhpur, during the period of September 2016–March 2019 were retrospectively studied. Parameters studied included age, gender, side of hernia, technique used, operating time, complications, and hospital stay. Patients were divided into two groups depending on whether the hernial sac was divided or not divided before taking a purse-string suture.
Statistical Analysis Used: Student's t-test and Fischer exact test were used to analyze data.
Results: A total of 114 patients were included in the study. The median age was 36.4 months. Hernial sac was divided before suturing in 53 patients, while sac was left intact in 61 patients. The mean follow-up was 11.4 months (range: 4–16). Age, gender, side of hernia, complications, and hospital stay were comparable in both groups. There was a significant difference between the mean operating duration in patients who underwent division of hernia sac compared to patients in whom the sac was not divided before putting purse-string suture (92.5 min [45–150] vs. 65.7 [30–90], respectively, P = 0.0101). Hernia recurrence (3.8% in Group A vs. 1.6% in Group B) was comparable in the two groups.
Conclusions: Laparoscopic pediatric hernia repair done with or without dividing the peritoneal sac gives comparable results, however operative duration is less if sac is not divided.

Keywords: Hernia repair, laparoscopic, pediatric

How to cite this article:
Rathod KJ, Sikchi R, Vig A, Jadhav A, Saxena R, Pathak M, Bhatia P, Sinha A. Laparoscopic Inguinal Hernia Repair in Children: To Cut or Not to Cut is the Question?. J Indian Assoc Pediatr Surg 2021;26:107-10

How to cite this URL:
Rathod KJ, Sikchi R, Vig A, Jadhav A, Saxena R, Pathak M, Bhatia P, Sinha A. Laparoscopic Inguinal Hernia Repair in Children: To Cut or Not to Cut is the Question?. J Indian Assoc Pediatr Surg [serial online] 2021 [cited 2023 Jan 28];26:107-10. Available from: https://www.jiaps.com/text.asp?2021/26/2/107/310657

   Introduction Top

Inguinal herniotomy is one of the most common pediatric surgical procedures in childhood and infancy.[1],[2] High ligation of the peritoneal sac at internal inguinal ring (IIR) is the standard treatment. This can be achieved either by conventional open method or by laparoscopic technique. Open herniotomy is still considered gold standard operation, however, many pediatric surgeons are preferring laparoscopy these days as it offers a highly magnified view, leading to lesser and more precise dissection, thereby decreasing the chances of injury to vas and testicular vessels, shorter postoperative recovery, improved cosmesis, and comparable recurrence rates.[1],[2],[3]

With increasing interest in laparoscopic inguinal hernia repair, several techniques have developed over last two decades, which aim for improved outcomes. Variations include different approaches of IIR, mode of dissection of sac, and difference in suturing and knotting techniques.

There have been few previous studies which recommend that dissection and cutting the IIR prior to suturing has an added advantage of reduced risk of recurrence and postoperative hydrocele formation as compared to suturing the IIR without cutting the ring.[4] Here, we have conducted a retrospective analysis of our laparoscopic inguinal herniotomies and divided them into two groups based on cutting and not cutting the IIR prior to the suturing of sac.

   Subjects and Methods Top

We did a retrospective analysis of laparoscopic inguinal hernia repair operated at All India Institute of Medical Sciences, Jodhpur, India, during the period of September 2016–March 2019. Patients were divided into two groups depending on whether the hernial sac was divided or not before taking a purse-string suture.

Group A – laparoscopic division of hernial sac was done around the IIR followed by intracorporeal suturing of the incised sac; Group B – only intracorporeal purse-string suturing of hernia sac was done without division of the sac. Parameters studied included age, gender, side of hernia, technique used, operating time, complications, duration of hospital stay, and recurrence rate. All children who underwent laparoscopic repair for indirect inguinal hernia, both unilateral and bilateral, were included in the study.

Recurrent and complicated cases (cases with incarcerated hernia, cases with obstructed hernia, and cases with strangulated hernia) were excluded from the study.

Description of the techniques

In both groups, after induction of general anesthesia, the patient was placed in Trendelenburg's position. Supra-umbilical camera port was inserted by open method, followed by CO2 insufflation to create a pressure of 8–12 mmHg. 5-mm 30° telescope was used for visualization of the pelvis and IIR on both sides. Two 3- or 5-mm lumbar ports were inserted for instrumentation under direct vision. In Group A, the peritoneum is incised lateral to the IIR and then dissected circumferentially, protecting the vas and vessels [Figure 1]. The peritoneum was lifted, and a small nick was made which was gently widened, and the vas and vessels were gently pulled away to prevent injury. After dissection, the sac was closed by a purse-string suture using Prolene Suture size 3-0 or 4-0. The suture needle was introduced into the peritoneal cavity either from the port site or by puncturing the lower abdominal wall. In Group B, laparoscopic purse-string suture was taken at the IIR by 3-0 or 4-0 Prolene Suture, using Maryland forceps and laparoscopic needle holder, to close the hernia sac, thereby leaving the distal sac intact [Figure 2]. Spermatic vessels and vas deferens were protected during the procedure. The abdomen was deflated, and port sites were closed using Vicryl 3-0. The skin was closed using Monocryl 5-0. No antibiotics were given in the perioperative period. The patients were discharged when they were pain free and accepting well orally.
Figure 1: Dissection of the sac around the internal inguinal ring before suturing it

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Figure 2: Purse-string suturing of sac without division of the sac

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   Results Top

A total of 138 indirect inguinal hernia sacs were closed (53 right, 37 left, and 24 bilateral) in 114 children (78 boys and 36 girls), ranging in age from 1 month to 16 years (median age, 36.4 months). No direct or femoral hernias were found in any of the patients. Group A included 53 patients, whereas Group B had 61 patients. Except for the operative duration, all of the studied parameters were comparable in both groups. The mean operating time was 92.5 (45–120) min in Group A (sac divided) and 65.7 (30–90) min in Group 2 (sac not divided). The operative duration is recorded from the time of induction of anesthesia. The mean hospital stay was comparable in both groups. None of the patients in either group had any surgical site-related complications. In Group A, one patient each had injury to the testicular vessel and injury to the vas deferens. In Group B, one patient had postoperative hydrocele which was managed conservatively. The mean follow-up was 11.4 months (4–16 months), Group A = 10.5 months and Group B = 9.6 months. A total of three patients (2.6%) had recurrence on follow-up. Two of these patients were in Group A, whereas one patient was in Group B. All these three patients were managed by redo-laparoscopic hernia repair without dividing the sac. No conversion to open was required in any case. [Table 1] represents the comparison of study parameters between the two groups.
Table 1: Comparison of the study parameters between the two groups

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   Discussion Top

With the advent of minimally invasive surgery and the availability of smaller instruments, laparoscopic hernia repair has become widely acceptable as the treatment of pediatric inguinal hernias. Minimally invasive techniques offer greater magnification, visualization of the contralateral IIR, better cosmesis, lesser postoperative discomfort, and faster recovery. The learning curve for laparoscopic surgery is considered a major hindrance in initiating it; however, we believe that this has significantly changed in our practice with the availability of laparoscopic simulators.

Several novel techniques of laparoscopic hernia repair have been published in the last two decades. All these techniques aim toward reducing the recurrence rate associated with laparoscopic technique. Some of these are applying a purse-string knot and reinforcing it with lateral umbilical ligament, followed by a stress test by increasing intraperitoneal CO2 pressure as proposed by Chan, closure of the peritoneum with interrupted sutures as proposed by Schier, suturing of the IIR by two Z sutures, use of N suture for closure of IIR, and Subcutaneous Endoscopically Assisted ligation (SEAL) of the hernial sac.[5],[6],[7],[8],[9] Furthermore, various technical refinement such as deflation of the abdomen to reduce the tension over the suture, injection of normal saline along the IIR for better prominence, and squeezing the scrotum to empty the sac have also been described in literature.[10]

However, the oldest, most widely practiced laparoscopic technique is intracorporeal suturing of the IIR using three ports.[6] An important consideration to prevent recurrence is to take a purse string with a nonabsorbable suture material circumferentially without any skip areas. It is seen that recurrence rates decline with an increase in the experience of a surgeon as there is lesser chance of leaving any gaps between subsequent bites of a purse string.[10]

According to previous literature, the time taken for laparoscopic hernia repair ranges from 25 to 74 min.[7],[11] In our study, the mean operating duration of Group A was 92.5 min, while that of Group B was 65.7 min, thereby showing a significant difference between the two groups. The operative time appears a little more in our series as it also included anesthesia time.

Complications in hernia repair did not seem to depend on the technique used. In Group A, injury to vessel and vas deferens was reported in one patient each during dissection, whereas in Group B, one patient developed postoperative hydrocele, which was managed conservatively. Shalaby et al. have previously reported that 4% of their cases developed scrotal hydrocele that were treated conservatively without surgery, which is comparable to our study.[9]

Recurrence rate after laparoscopic inguinal hernia repair in many series is from 0.7% to 4.5%.[11] In the current study, we had a total of three recurrences (division of sac group – 3.8% vs. no division of sac group – 1.6%, P = 0.596). These three patients were successfully managed by redo-laparoscopic repair without dividing the sac. The present series thereby suggests that cutting the ring prior to primary closure has no added advantage over simple purse-string suturing of the IIR. However, the former group has greater operative duration and increased likelihood of injuring the spermatic cord as compared to the no division of sac group.

The criteria of choosing the type of laparoscopic herniotomy at our center depend on the operating surgeon's preference. We also believe that previous training in laparoscopic procedures might also influence the type of herniotomy done. However, recently published International Pediatric Endosurgery Group evidence-based guideline on minimally access approaches to the operative management of inguinal hernia in children could not satisfactorily identify that any of the various described methods is superior to other.[12]

   Conclusions Top

Laparoscopic pediatric hernia repair done with or without dividing the peritoneal sac gives comparable postoperative outcomes. However, there is greater risk of injury to vas deferens and testicular vessels and also longer operative duration when division of sac is done prior to its ligation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Lee Y, Liang J. Experience with 450 cases of microlaparoscopic herniotomy in infants and children. Pediatr Endosurg Innov Tech 2002;6:25-8.  Back to cited text no. 1
Schier F, Montupet P, Esposito C. Laparoscopic inguinal herniorrhaphy in children: A three-center experience with 933 repairs. J Pediatr Surg 2002;37:395-7.  Back to cited text no. 2
Clarke S. Pediatric inguinal hernia and hydrocele: An evidence-based review in the era of minimal access surgery. J Laparoendosc Adv Surg Tech A 2010;20:305-9.  Back to cited text no. 3
Abd-Alrazek M, Alsherbiny H, Mahfouz M, Alsamahy O, Shalaby R, Shams A, et al. Laparoscopic pediatric inguinal hernia repair: A controlled randomized study. J Pediatr Surg 2017;52:1539-44.  Back to cited text no. 4
Chan KL. Laparoscopic repair of recurrent childhood inguinal hernias after open herniotomy. Hernia 2007;11:37-40.  Back to cited text no. 5
Schier F. Laparoscopic inguinal hernia repair-a prospective personal series of 542 children. J Pediatr Surg 2006;41:1081-4.  Back to cited text no. 6
Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998;33:1495-7.  Back to cited text no. 7
Schier F. Laparoscopic surgery of inguinal hernias in children--initial experience. J Pediatr Surg 2000;35:1331-5.  Back to cited text no. 8
Shalaby R, Ismail M, Dorgham A, Hefny K, Alsaied G, Gabr K, et al. Laparoscopic hernia repair in infancy and childhood: Evaluation of 2 different techniques. J Pediatr Surg 2010;45:2210-6.  Back to cited text no. 9
Shalaby R, Ismail M, Samaha A, Yehya A, Ibrahem R, Gouda S, et al. Laparoscopic inguinal hernia repair; experience with 874 children. J Pediatr Surg 2014;49:460-4.  Back to cited text no. 10
Tsai YC, Wu CC, Yang SS. Minilaparoscopic herniorrhaphy with hernia sac transection in children and young adults: A preliminary report. Surg Endosc 2007;21:1623-5.  Back to cited text no. 11
Davies DA, Rideout DA, Clarke SA. The international pediatric endosurgery group evidence-based guideline on minimal access approaches to the operative management of inguinal hernia in children. J Laparoendosc Adv Surg Tech A 2020;30:221-7.  Back to cited text no. 12


  [Figure 1], [Figure 2]

  [Table 1]


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