Raghavendra Rao, MD, Michael Smith, Troy Markel, MD, Brian Gray, MD, Matthew Landman, MD. IU
Introduction: The subcutaneous endoscopic assisted ligation (SEAL) is a technique of pediatric laparoscopic hernia repair which has recently been incorporated by pediatric surgeons. This technical details of SEAL remain controversial. We present the outcomes of our large experience with this technique in comparison with open inguinal hernia repairs (OHR) in the pediatric population.
Methods: Demographic data, operative times, operative details and recurrence/complication rates were retrospectively reviewed for both the SEAL and OHR done between Jan-2017 to Sept-2018. Non-parametric tests were used to detect differences, and p<=0.05 was regarded as statistically significant. SEAL was performed as previously described in a rabbit model along with fulguration of sac[1]. Matching was done using propensity-score analysis.
Results: There were 213 OHRs and 90 SEAL procedures during the study period(Table).
For OHR, laparoscopic-look was performed in 23%. When successful, it revealed a contralateral PPV (patent processus-vaginalis) in 41% of cases, all of which were repaired. For the SEAL procedures, a contralateral PPV was found in 25%, all of which were repaired. There were no intraoperative complications for either technique.
OHRs had a recurrence rate of 0.4% (n=1) and 1.4% metachronous hernias (n=3). No patient had a lap look in the patients with metachronous hernias. SEAL repairs had 3 recurrences (3.3%,p=0.08). The post op complication rate for OHR was 2.8% [postoperative pain-2.3% and infection-0.4%]. There were 4 post-op complications with the SEAL technique (4.4%,p=0.6). Two of them were incisional infections, 1 a prominent retained suture and fourth excessive granulation at the umbilical trocar site.
90 SEAL procedures were matched to 90 OHRs using propensity-score analysis based on age, sex, follow-up time, hernia side, repair of contralateral-hernia and number of additional procedures. There were no differences in recurrence-rates (1 vs. 3 in OHR and SEAL respectively,p=0.6), complication-rates (1 vs. 4 in OHR and SEAL respectively,p=0.4) and OR-time [44.5 vs. 43 min in OHR and SEAL respectively,p=0.8].
Conclusions: The SEAL has similar OR-time and outcomes compared to OHR. Contralateral PPVs are very common and lead to metachronous hernias. SEAL has the advantage of more easily being able to detect contralateral PPVs and involves little cord dissection. Our study was limited by short follow-up. Greater experience should lead to better outcomes with SEAL.
| OHR | SEAL | |
| N | 213 | 90 |
| Isolated hernia repairs | 162(76%) | 55(61%)* |
| Age(median[IQR] days) | 420[96-1936] |
149[95-673] ** |
| Sex(female%) | 23 | 23 |
| Additional Procedure(%) | 24 | 39* |
| Follow-up(median [IQR] days) | 29[1.0-189] | 41.5[2.0-149.8] |
| OR-time(median[IQR] min) | 39[28-63] | 43[36-64.3]* |
|
Index side of hernia(%) Left Right Bilateral |
31 51 18 |
38*** 42 20 |
| OR-time of Isolated hernia repairs (median[IQR] min) | 35[26-49] | 38[32-45] |
*p<0.05.**p<0.005.***p<0.001
[1]Bruns NE et-al. Assessing the Adequacy of Absorbable Braided Suture for Laparoscopic High Ligation in Rabbits. J-Laparoendosc-Adv-Surg-Tech A.2017 Jul;27(7):733-736
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 98648
Program Number: ETP747
Presentation Session: Emerging Technology Poster Session (Non CME)
Presentation Type: Poster