Laparoscopic repair of hernia in children: Comparison between ligation and nonligation of sac.

AIM: The essence of the current techniques of laparoscopic hernia repair in children is suture ligation of the neck of the hernia sac at the deep ring with or without its transection. Some studies show that during open hernia repair, after transection at the neck it can be left unsutured without any consequence. This study was aimed to see if the same holds true for laparoscopic hernia repair.
MATERIALS AND METHODS: Sixty patients (52 boys and eight girls, 12-144 months) with indirect inguinal hernia were randomized for laparoscopic repair either by transection of the sac alone (Group I) or transection plus suture ligation of sac at the neck (Group II). Outcome was assessed in terms of time taken for surgery, recurrence, and other complications. RESULT: Thirty-eight hernia units in 28 patients were repaired by transection alone (Group I) and 34 hernia units in 29 patients were repaired by transection and suture ligation (Group II). Three patients were found to have no hernia on laparoscopy. Recurrence rate and other complications were not significantly different in the two groups. All recurrences occurred in hernias with ring size more than 10 mm.
CONCLUSION: Laparoscopic repair of hernia by circumferential incision of the peritoneum at the deep ring is as effective as incision plus ligation of the sac.

RCT Entities:   Population Interventions Outcomes

INTRODUCTION

Although many techniques have been described for laparoscopic hernia repair,[123456789] suture closure of the peritoneum at the deep ring is common to all. Techniques have been described to incise the peritoneum at the deep ring in addition to suture.[1011] In open hernia surgery it has been shown that suture ligation of the sac following its transection at the deep ring is not an essential step, both in adults and children.[12131415] During laparoscopic[1617] and open orchidopexy,[18] the associated hernia sac has been left unsutured without any consequences. The technique of transection alone has been anecdotally applied to laparoscopic hernia repair also.[19]

The aim of this study was to compare the two methods of laparoscopic hernia repair in children, that is, transection of sac alone and transection of sac along with suture ligation at the neck.

MATERIALS AND METHODS

Sixty patients of indirect inguinal hernia (1-12 years of age) were randomized to undergo laparoscopic hernia repair either by simple transaction of the sac at the neck (Group I) or by transection and suture ligation of the sac at the neck (Group II).

The exclusion criteria were: Infants (below 1 year), obstructed/irreducible hernia, previous history of laparotomy, existing contraindication to laparoscopy, connective tissue disorders, ascites, children with ventriculoperitoneal shunts, failure to obtain consent, and recurrent hernia.

Operative techniques

Group I (transection of the sac, no suture)

Primary umbilical port (5 or 10 mm) was inserted by open cannulation. Pneumoperitoneum was created at a pressure of 10 mmHg. Inguinal anatomy was assessed with a straight telescope. Two 5 mm working ports were inserted one on each side of the umbilicus. A hernia was defined as an open deep inguinal ring of any size [Figure 1a]. Size of the open ring was measured with open jaws of a 5 mm Maryland forceps. The span of the open jaws of the forceps was premeasured. The peritoneum was lifted off the vessels medially and incised [Figure 1b]. Safeguarding the vas and vessels the incision was completed circumferentially [Figure 1c]. The distal sac was seen to recede thus indicating complete transection.

Figure 1

(a) Laparoscopic view of left-sided hernia. (b) Peritoneum incised medially over the vessels. (c) Circumferential incision completed. Vas and vessels are clearly visible and safe

In girls, the procedure involved division of the round ligament as well.

Group II (transection of the sac and suture ligation)

All steps as in the above technique were followed. In addition, the resultant peritoneal defect was closed by “figure of eight” stitch of 4/0 vicryl using intracorporeal knotting [Figure 2a and b].

Figure 2

(a) Figure of eight stitch has been applied to ligate the sac. (b) Knot has been tied to ligate the sac and complete the procedure

An open ring on the contralateral side, irrespective of its size, was considered as a hernia and repaired in the same manner. The operative time was recorded from skin incision to closure of port sites. Postoperative analgesia was given with rectal/oral paracetamol. A patient was considered fit for discharge when fully awake and had accepted at least one feed without vomiting, and had passed urine. Complications if any were recorded. Follow-up was at 1 week, 1 month and 6 months.

Statistical analysis

Outcomes in the two groups, for example, pain and requirement for analgesics, port site complications, hydrocele, and recurrence were compared using the chi-square (χ2) of Fisher's exact test. Difference in operating time was studied using Mann-Whitney test.

RESULTS

There were 52 (86.7%) boys and eight (13.3%) girls. Age range was 12-144 months (mean 63.15 months). On clinical history the hernia was right-sided in 38, left-sided in 19, and bilateral in three. On clinical examination hernia was elicited in all but four cases; these were operated on the basis of parental history alone; two of them did not have a hernia on laparoscopy, but the other two had a hernia and were operated accordingly. One patient, in whom a left hernia swelling had been elicited on examination, was found to have no hernia on laparoscopy. Thus, three patients were found to have no hernia at laparoscopy and hence were excluded from the study. Of the 38 clinically elicited right hernias, six (15.8%) were found to be bilateral at laparoscopy. Of the 17 clinically elicited left hernias, six (35.29%) were found to be bilateral. The overall incidence of laparoscopic bilaterality in unilateral presentation was 21.8%. All three clinically bilateral hernias were proved to be so laparoscopically. As a consequence of detection of contralateral hernia, the total number of open internal rings (considered as hernia unit) went up to 72, out of which 47 (65.27%) were on right side and 25 (34.72%) on left side. Group wise distribution was:

Group I: 28 patients, 38 hernia units.

Group II: 29 patients, 34 hernia units.

The operation was successfully completed in all. No conversion was required. Size of the deep inguinal ring varied from 2 to 20 mm. An additional procedure for a concomitant pathology was performed in nine cases: Repair of umbilical hernia (three), excision of lymph node near external iliac vessels (one), partial omentectomy for adherent omentum (one), division of internal bands (two), excision of a lymphatic cyst at the deep ring (one), and excision of abdominal component of a communicating hydrocele (one). These cases were not taken into account for comparing the time taken for surgery.

Figure 3a and b shows the time taken for surgery in groups I and II, respectively. All except three unilateral hernias in group I were performed within 30 min, all bilateral were done within 50 min except one. In group II unilateral hernia repair took <30 min in 11 cases, 30-40 min in six cases, and >50 min in two cases. It varied from 40 to 90 min for bilateral repair in this group. While the difference in time taken between the two groups was significant for unilateral hernia repair (P = 0.016), it was not found significant for bilateral hernia repair (P = 0.073).

Figure 3

(a) Operative time in group I. (b) Operative time in Group II

Complications

Recurrence occurred in three out of 72 hernia units (4.2%). Group wise it was 2/38 in group I (5.3%) and 1/34 in group II (2.9%). The difference was not statistically significant (P = 0.623). All the three recurrences occurred on the right side with a ring size > 10 mm. Two of them were early recurrences (24-72 h), while one occurred after 5 months. They were all repaired by open technique subsequently.

Other than recurrence the following minor complications were also observed: Self-resolving hematoma near the deep ring (one case), transient hydrocele lasting for 72 h (one case in each group), transient scrotal pneumatocoele (two cases in group I and one in group II), and port site emphysema (one case in each group). There was no statistically significant difference in these complications in the two groups.

Fifty out of 57 (88.3%) patients were fit for discharge within 8 h of surgery with similar distribution in the two groups. Of the remaining seven patients, five were fit at 24 h. These were the patients who were kept under observation for either pain, surgical emphysema at port site, or pneumatocele. Of the remaining two, one was discharged on the 3rd postoperative day as he developed a hematoma near the deep ring. The other developed recurrence on the 1st postoperative day and was reoperated. He was discharged the following day. There was no further complication noted during the follow-up of 6 months.

DISCUSSION

Laparoscopic hernia repair in children has developed significantly in the past 10 years. Clear advantages have been realized such as better visualization of the vas and vessels, less risk of injury to them, no risk of iatrogenic cryptorchidism, ability to diagnose and treat contralateral hernia, negligible wound-related complications, better assessment of internal genitalia in females, and other benefits of minimally invasive surgery. Laparoscopic hernia repair has even been projected to be the future gold standard in pediatric hernia repair.[1]

Several techniques have been described: Closure of the peritoneum at the deep ring by a suture without incising the peritoneum (as popularized by Shier) with either a Z-stitch at the deep ring[2] or an interrupted stitch,[3] partial incision of the periorificial peritoneum followed by purse string suture at the deep ring,[4] elevation of peritoneum with saline injection before purse string suture,[5] flip flap hernioplasty using peritoneal flap,[6] and subcutaneous extracorporeal suturing under laparoscopic guidance;[789] complete transection of the sac at the deep ring with suture closure of the peritoneal defect.[1011] All these techniques have used a suture at the deep ring either with or without incising the peritoneum.

Traditional teaching on open herniotomy emphasizes on suture ligation of the peritoneal end of the sac following its transection at the deep ring. However, there have been reports, both in adults and children, to suggest that leaving the sac unligated following transection does not make any difference in the outcomes of open hernia repair.[12131415] These reports are backed with several studies on peritoneal healing that suggest peritoneal regeneration by metamorphosis of the in situ mesodermal cells in the raw areas rather than by growth from the edges, resulting in rapid healing of even large defects.[20212223] In fact during laparoscopic[1617] and open orchidopexy,[18] the hernia sac has been left unsutured without any adverse outcome. Riquelme et al.,[19] has also demonstrated that transection of sac alone is sufficient for treatment of inguinal hernia in children. We want to emphasize on completeness of the transection to prevent recurrence. It is important to see the distal sac recede into the inguinal canal as a proof of completeness of transection. In Riquelme's series a purse string closure of the ring was done for >10 mm size of the deep ring. He did not report any recurrence in a 4 year follow-up. In our series all the recurrences were associated with ring size of more than 1 cm. On the other hand there were 11 hernia units with ring size more than 1 cm in group I where there was no recurrence. Ours and Riquelme's studies do indicate that for large hernias (>10 mm) suture closure of the peritoneum could be adopted in addition to transecting the peritoneum at the neck.

Our preliminary results show that both the techniques are comparable in terms of complication rate and recurrences. Although the absolute numbers suggest a higher recurrence in group I (2 vs 1) it is statistically insignificant.

Limitations of the study

Infants have not been included in the study. The length of the inguinal canal and obliquity develops during infancy to make an effective sealing mechanism at the deep ring. It is logical for the critics to believe that leaving the peritoneum unsutured may invite more recurrences in infants due to a suboptimal sealing mechanism of the conjoint muscle. However, there are several patients in the series between 1 and 2 years, which have not shown any recurrence. The only recurrence in 1-2 year bracket occurred in group II. Total number of cases is small for a recommendatory suggestion. This small number was due to the time constraint as it was a 1 year study conducted as Majister chirurgiae (MCh) thesis. We admit that a larger series would be more meaningful.

CONCLUSION

Laparoscopic repair of hernia by circumferential incision of the peritoneum at the deep ring may develop as a favored alternative technique, at least in hernias with ring size <10 mm, because of its simplicity. Ligation of the sac made no difference in the outcomes in this series.