Lauren E McClain, MD, Christian Streck, MD, Aaron Lesher, MD, Andre Hebra, MD. Medical University of South Carolina.
Background: For decades open inguinal hernia repair(Ferguson repair) has been the gold standard in treatment of inguinal hernias in children. Recurrence and complication rates are low and patient satisfaction is high, however, we propose a new method for inguinal hernia repair using laparoscopic techniques with comparable outcomes.
Objective: We describe our technique and experience with the laparoscopic needle-assisted repair of inguinal hernia(LNAR). We report 502 cases (710 hernias) from 2009-2013 by 3 surgeons.
Methods: We retrospectively reviewed a prospectively collected outcomes database of all patients receiving laparoscopic needle-assisted repair of inguinal hernia from January 2009-March 2013. 502 cases in 495 patients <13 years old with 710 inguinal hernias were identified for analysis and review. Hernia repair is accomplished with a single port needle-assisted technique. The internal inguinal rings are identified to confirm patent processus vaginalis and to evaluate for occult contralateral hernia. The ring is encircled in an extraperitoneal plane using a 22G Touhy needle for placement of a purse-string suture. The knot is tied extracorporally and then buried beneath the skin. The technique was standardized for all cases.
Results: 710 inguinal hernias were laparoscopically repaired in 495 patients (408 boys & 87 girls). Patients’ age ranged from 11 days-12.8 years with a mean of 29.2 months and median of 15.5 months. 294 had unilateral repair (199 right & 95 left) and 208 had bilateral inguinal hernia repair. Mean operating time for unilateral hernia was 20.5 minutes (range 8-57 min) and bilateral hernia was 26.4 minutes (range 12-51min). 150 of the patients who underwent bilateral hernia repair were diagnosed as having unilateral hernia preoperatively. 21 minor complications were identified and included 9 superficial wound infections, 8 suture granulomas, and 4 recurrent hydroceles. 4 recurrences (1 Preterm and 3 Term) have been identified in our data. Mean time since surgery is 30 months (range 3-54 months). Mean follow-up was 10.7 months (range 0.3-38.4 months). Follow-up included: Long-term (1 year) on 208 patients, medium-term (1-11 months) on 64 patients, and short-term (<1 month but > 1week) on 194 patients.
Conclusion: Post-operative data shows our technique is safe with a 4 % (8 granuloma, 4 persistent hydroceles, 9 wound infections) rate of minor complication. Recurrence rate was 0.56% for the total number of hernias (4/710). This makes recurrence rate comparable to classical open technique although further follow-up is required for additional post op data. Furthermore, laparoscopy objectively identifies asymptomatic or occult contralateral defect; uses a smaller incision; and eliminates dissection of the cord structures potentially reducing the risk of cord injury. LNAR is a safe and possibly very effective technique for minimally invasive inguinal hernia repair in children.