Introduction

Recently, laparoscopic inguinal herniorrhaphy has been introduced as an alternative to conventional open repair in children [1–7]. In our institute, laparoscopic surgery in girls with inguinal hernia was started in 2001 and since then the use of laparoscopic procedures has increased rapidly. The laparoscopic percutaneous extraperitoneal closure (LPEC) method, which was originated by Takahara et al. [4], is employed. We perform the procedure using a new device called the “LapaherclosureTM” (Hakko Medical Co., Tokyo, Japan) to place a purse-string suture around the internal inguinal ring. This procedure easily allows contralateral exploration and immediate closure of the contralateral patent processus vaginalis (PPV) in only 5–10 min without the need for additional trocar. This can prevent a second operation and thereby reduce both economic burden and procedural risks to patients. In this study, we compared this laparoscopic procedure with conventional open herniorrhaphy and evaluated the utility, efficacy, and safety of this minimally invasive approach. Moreover, we measured the length of hernial sac and PPV using a “snake retractor” to elucidate the nature of contralateral development of hernias.

Materials and methods

Patients

Between March 2001 and December 2002, 129 girls with inguinal hernia received laparoscopic herniorrhaphy (laparoscopic group). Their mean age was 4 years and 4 months (range 4 months–13 years); 53 cases (41%) were left side, 62 (48%) were right side, and 14 (11%) displayed bilateral hernia. During the same period, 21 girls with inguinal hernia underwent conventional open herniorrhaphy (control group). The surgical method was chosen by the parents. Mean age was almost identical between the laparoscopic group and the control group. Mean operational time, anesthesia time, complications, recurrence rates, and medical costs were compared between the two groups (Table 1).

Table 1 Operative time, anesthetic time, and hospital days
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Surgical method

The patients were placed in a supine position and received general anesthesia with tracheal intubation. A 5 mm trocar for a 5 mm laparoscope was inserted via the umbilicus. Following the establishment of pneumoperitoneum with a pressure of 8 mmHg, a 30° 5 mm laparoscope was inserted through the umbilicus, a 3 mm trocar was positioned via the lateral abdominal wall, and 3 mm grasping forceps were inserted to manipulate the peritoneum near the hernia defect (Fig. 1). The asymptomatic contralateral internal inguinal ring was routinely evaluated for a PPV. The length of the hernial sac and PPV were measured using a 3 mm flexible retractor (Diamond-Flex Snake RetractorTM, Snowden Pencer, USA) to define the relation of age, side, and clinical signs of inguinal hernia. The retractor consists of multiple segments and a flexible tip and can therefore be inserted through both the internal inguinal rings to measure the length of the hernial sac or PPV (Fig. 2).

Fig. 1
figure 1

Laparoscopic herniorrhaphy. A 30° 5 mm laparoscope was inserted through the umbilicus, while a 3 mm trocar was placed via the lateral abdominal wall with insertion of 3 mm grasping forceps. A special needle (LapaherclosureTM) with suture is passed at the level of the inguinal ring to place the purse-string suture around the internal inguinal ring

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Fig. 2
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Measurement of hernia sac/PPV. The length of the hernial sac/PPV was measured using a 3 mm flexible retractor (Diamond-Flex Snake RetractorTM). The retractor consists of multiple segments and a flexible tip and can be inserted through both the internal inguinal rings to measure the length of the hernial sac or PPV

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The internal orifice of the inguinal canal was closed with a purse-string suture of 2-0 non-absorbable suture thread using a Lapaherclosure™, a special needle that has a wire loop to hold the suture thread at the tip (Fig. 3). This needle, with an outer diameter of 1.5 mm, is inserted through the abdominal wall together with the 2-0 non-absorbable suture at the midpoint of the right or left inguinal line. One half of the purse string suture was begun extraperitoneally from the anterior to the posterior edge on one half of the internal inguinal ring. After that, the suture thread was removed from the needle and the opposite half of the rim of the internal ring was closed with a purse-string suture using the same technique. The Lapaherclosure was then removed from the abdomen together with the suture thread. The purse-string suture was tied extracorporeally, and the internal inguinal ring was then completely closed (Fig. 4). If the contralateral processus vaginalis was open, it was closed using the same approach. Patients were admitted in the morning and discharged the afternoon of the same day (outpatient or “day care” surgery).

Fig. 3
figure 3

Lapaherclosure. The internal orifice of the inguinal canal was closed with purse-string sutures of 2-0 non-absorbable suture thread using a Lapaherclosure™, a special needle that has a wire loop to hold the suture thread at the tip

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Fig. 4
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Operational technique. a Using the grasper for traction, the needle and suture are passed around the lateral aspect of the hernia sac at the level of the inguinal ring, remaining extraperitoneal until half of the sac has been surrounded. The peritoneum was pierced with the needle, and the end of the suture was removed from the needle using the grasper. b The needle is withdrawn and the empty needle is then inserted and passed around the medial half of the neck of the hernia defect. The peritoneum is reentered where the suture enters the peritoneal cavity. c The intraperitoneal end of the suture is passed through the wire and held. d The needle is again withdrawn with the suture. e The suture is tied extracorporeally, completing an extraperitoneal high ligation of the sac. f After cutting the excess suture, the knot retracts subcutaneously

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Results

The mean operating time for laparoscopic herniorrhaphy was 48±15 min (range: unilateral 45±16 min, bilateral 54±13 min), while anesthetic time was 92±17 min (range: unilateral 88±17 min, bilateral 96±15 min). With experience, the time gradually decreased. At present, a skilled operator can perform a laparoscopic bilateral herniorrhaphy within 30 min. Operating and anesthetic times were significantly longer than those of conventional open herniorrhaphy (P<0.05; Table 1).

The average medical cost of laparoscopic herniorrhaphy was about 3,140 euros, whereas that of conventional herniorrhaphy was about 1,240 euros in unilateral hernias and 1,970 euros in bilateral cases. Except for minor bleeding from peritoneal vessels, there were no major intra- or post-surgical complications observed in either laparoscopic or conventional herniorrhaphy.

Contralateral asymptomatic PPV was observed in 21 of 62 (33.9%) right-side and 19 of 53 (35.8%) left-side hernias. Therefore contralateral PPV was present in 34.8% (40 cases) of the 115 patients who showed clinical evidence of unilateral inguinal hernia. In those patients, we performed prophylactic laparoscopic closure of the opened processus vaginalis. The laparoscopic approach leaves a very small scar with excellent cosmetic results. The average follow-up time of patients was 28 months (range 12–48 months), and there was no recurrence or subsequently developed contralateral inguinal hernia.

Measurement of the length of the hernial sac and PPV (Table 2) has proven that the hernial sac (5.5±1.3 cm; n=65) was significantly longer than the contralateral asymptomatic PPV (4.0±1.9 cm; n=13) (P<0.05). There was no significant difference between the left side (5.4±1.6 cm; n=43) and right side (5.0±1.5 cm; n=40). The minimum length of a symptomatic hernia sac was 27 mm. There was no significant relationship between the length of the hernia sac or PPV and age (Fig. 5).

Table 2 Length of the hernia sac/PPV (cm)
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Fig. 5
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Relation between the length of the sac/PPV and age. No significant correlation was observed. The minimum size of a hernia sac was 27 mm

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Discussion

The initial use of laparoscopy in the pediatric hernia patient was to examine the contralateral groin, either through a port or the opened hernia sac, during open unilateral hernia surgery [8–11]. Recently, the use of laparoscopic herniorrhaphy in pediatric surgery has jumped due to improvements in laparoscopic techniques [1–7]. Reported excellent outcomes in large studies have confirmed that laparoscopic herniorrhaphy in children is an acceptable alternative to the traditional open approach.

Reported advantages of laparoscopic herniorrhaphy include minimizing dissection as well as reducing trauma to the inguinal canal and spermatic cord. There is no longitudinal skin incision in the abdominal wall, leading to better cosmetic results, and the risk of infection is less compared with the traditional open approach. We use 3 mm instruments, which are inserted through 3 mm trocars, leaving virtually no scar. Bilateral hernia can be repaired with the same wound. In addition to these advantages, we believe that the greatest benefit from this technique is the opportunity to evaluate the contralateral side. The incidence of contralateral hernia after unilateral herniorrhaphy is reported to be 8.8–11.6% [12–14]. In our experience, prior to the introduction of laparoscopic herniorrhaphy, contralateral hernia was observed within 5 years in 6.5% (27 of 415 cases) of girls who received conventional unilateral inguinal hernia repair. However, there was no contralateral hernia observed after laparoscopic herniorrhaphy in our series. These findings suggest that contralateral exploration and prophylaxis closure of PPV during laparoscopic herniorrhaphy can prevent the occurrence of contralateral inguinal hernia.

The relationship of the length of processus vaginalis to the development of hernia is still unknown. In this study, we measured the length of the hernia sac and PPV using an Endo SnakeTM. The results have shown that hernia sac was significantly longer than an asymptomatic PPV without hernia. One reason is that the hernia sac may be enlarged by the incarcerated organs. Another possibility is that a small PPV may not develop into a clinical hernia. In this study, the minimum size of a hernia sac was 27 mm. Based on this, we consider that PPV which are smaller than 20 mm are unlikely to develop into clinical hernias, making a closure procedure unnecessary.

There have been numerous reports describing various laparoscopic techniques for pediatric inguinal hernia repair [1–7]. In most of these series, an intracorporeal purse-string suture or Z sutures were placed around the neck of the hernia sac, which is then closed intracorporeally. However, we have introduced a new technique in which the neck of the hernia sac is closed with an extraperitoneal purse-string suture. The suture is applied using a special needle designed specifically for laparoscopic herniorrhaphy. This needle—LapaherclosureTM—is commercially available from Hakko Medical Co., Tokyo, Japan.

The recurrence rate of inguinal hernia has been reported to be slightly higher with laparoscopic herniorrhaphy than with the conventional technique. Montupet and Esposito [2] reported that in two of 45 patients (4.4%) there was a recurrence on the same side. However, the results of our series show that our procedure has a high success rate and a low incidence of complications; there was no recurrence and no major complications in any patient within 2 years. Endo and Ukiyama [5] also reported on the similar technique of extraperitoneal closure of hernia sacs using the Endoneedle, with no complications and low recurrence rates (0.88%). The low incidence of recurrent hernia in our procedure may be due to extraperitoneal closure and extracorporeal ligature, which provide more accurate closure of the hernia sac.

We first performed laparoscopic herniorrhaphy only in girls to avoid the risk of injury to the vas deferens or the blood supply of the testis and iatrogenic ascent of the testis. It has been reported that damage to the vas deferens and blood supply to the testes may cause atrophy of the testis, diminished size of the testis, and iatrogenic cryptorchism [15]. Now that the procedure’s techniques have been established and operators are more skilled, we are planning to extend the procedure to boys.

We believe that the technique described here is an effective and reliable therapy. Contralateral exploration and closure of asymptomatic PPV can prevent the occurrence of contralateral inguinal hernia and thereby preclude the need for additional surgery later. We conclude that the LPEC method is a safe and efficacious procedure that should be viewed as an acceptable alternative to the traditional open approach.