Percutaneous Internal Ring Suturing for the Minimal Invasive Treatment of Pediatric Inguinal Hernia: A 5-Year Single Surgeon Experience

Abstract

Purpose: Percutaneous internal ring suturing (PIRS) is a minimally invasive surgical technique of laparoscopic hernia repair in children under the control of a laparoscope placed in the umbilicus. The aim of this study was to evaluate the management and postoperative outcomes of PIRS for inguinal hernia repair in children.Patients and Methods: All children who underwent PIRS for an inguinal hernia, between February 2015 and February 2020, were included in the prospective cohort study. The following parameters were recorded: age, gender, body mass index, lateralization of hernia, surgical and anesthesia times, level of pneumoperitoneum, additional trocar introduction, length of hospital stay, and intraoperative or postoperative complications and recurrences were recorded.Results: A total number of 228 PIRS procedures were performed in 188 children [126 (67%) male individuals and 62 (33%) female individuals] with a median age of 4 [interquartile range (IQR), 2 to 6] years and a median follow-up of 46 (IQR, 38 to 52) months. From the total number of hernia repairs there were 99 (52.7%) right, 49 (26.1%) left, and 40 (21.2%) bilateral hernia repairs. Median surgical time was 10 (IQR, 8 to 12) minutes for unilateral and 16 (IQR, 14 to 20) minutes for a bilateral repair. The median hospital stay was 24 (IQR, 8 to 24) hours. Regarding intraoperative complications, only 3 (1.3%) inferior epigastric veins injuries were recorded, without any consequences. During the follow-up period in 3 male children, hydrocele was recorded; in 2 cases, hydrocele resolved spontaneously and 1 required surgical treatment. No cases of other complications including testicular atrophy or recurrence were recorded. Conclusion:In a hands of an experienced pediatric laparoscopic surgeon, PIRS is a simple, safe, and effective technique for inguinal hernia repair in children with excellent outcomes, cosmetic results, and a low incidence of complications and recurrence.

Learning Curve for Laparoscopic Repair of Pediatric Inguinal Hernia Using Percutaneous Internal Ring Suturing

“…With the development of minimally invasive surgery numerous laparoscopic techniques for pediatric inguinal hernia repair have been developed including intracorporeal suturing and an extracorporeal approach [ 1 , 2 , 3 , 4 , 14 , 16 , 17 ]. According to recent literature PIRS for pediatric inguinal hernia repair has been proven to be a safe and effective method [ 1 , 2 , 3 , 4 , 6 , 10 ]. It still remains an open question as to how much experience a surgeon needs to have to be able to perform this method safely without significant complications.…”

“…This had been influenced by the inexperience of the surgeons, the use of absorbable suture, and the use of a single suture or larger defects [ 21 ]. Recently, it has been described that PIRS resulted in a significant reduction of recurrence rates and operative time [ 2 , 3 , 4 , 5 , 10 ]. In this study postoperative hydrocele formation and recurrence rates were significantly greater in the first 30 patients and after that number of complications significantly decreased.…”

“…New studies have reported recurrence rates of 0.5–0.7%, which is very similar to those in open surgery [ 2 , 4 ]. Additionally, operative time was reported to be lower than open surgery, with unilateral hernias averaging 10 min and bilateral hernias 15 min [ 9 , 10 ]. Incidence of complications in the hands of experienced laparoscopic pediatric surgeon is very low.…”

“…The most common reported complications are injury to blood vessels, recurrence, hydrocele formation, knot reaction, severe pain, and scrotal swelling [ 1 , 4 , 9 , 10 ]. Care should be taken not to injure the spermatic cord or vessels, although the risk is significantly higher in traditional open surgery [ 1 , 9 , 10 ]. In the case of vascular structure injuries, laparoscopic surgery may be completed only in the absence of further bleeding and growth of retroperitoneal hematoma.…”

“…In the case of vascular structure injuries, laparoscopic surgery may be completed only in the absence of further bleeding and growth of retroperitoneal hematoma. If that is not possible, conversion to open surgery should be performed [ 10 ].…”