Algorithm of Laparoscopic Technique in Pediatric Inguinal Hernia: Results from Experience of 10 Years.

BACKGROUND: Many laparoscopic techniques have been evolved along years for pediatric inguinal hernia (PIH) with no standardization of technique. No single technique suits all varieties of hernia. PURPOSE: To propose an algorithm for allocation of PIH to laparoscopic technique based on internal ring (IR) diameter to improve outcomes. PATIENTS AND METHODS: Along 10 years, 459 cases with unilateral PIH were treated in Tanta University Hospital. In the first 5 years (phase I), 214 cases included then an algorithm for stratification was designed and applied in the second 5-year period (phase II), where 245 cases managed. This algorithm included evaluation of the hernia based on IR diameter as measured by the laparoscope from inside by a piece of suture. When the IR diameter is from 4 to 15 mm, complete sac disconnection is used. When IR diameter lies from 15 to 25 mm a purse string is added. When IR diameter is >2.5 cm or recurrent cases, the interrupted muscular arch repair after sac disconnection is used. RESULTS: In phase I, 170 boys and 44 girls from 6 to 180 months of age were treated. All cases managed by laparoscopy were 84 herniotomy, 82 by purse string, and 44 by interrupted muscular arch. In phase II, 180 boys and 65 girls from 3 to 180 months of age were included. Eighty were managed by herniotomy, 137 by purse string, and 25 by interrupted muscular arch. Recurrence rate decreased significantly in phase II. CONCLUSIONS: Application of Tanta algorithm reduces the recurrence rate significantly. The laparoscopic technique should be tailored according to criteria of each group of PIH to get the best outcome and reduced recurrence rate.

Laparoscopic Interrupted Muscular Arch Repair in Recurrent Unilateral Inguinal Hernia Among Children.

PURPOSE: We present a procedure of suturing the transversus abdominis muscular arch to the ileopubic tract laparoscopically in order to repair recurrent unilateral pediatric inguinal hernia (PIH). PATIENTS AND METHODS: Twenty-five children with recurrent unilateral PIH were treated during a 5-year period in a tertiary academic center. All cases were subjected to laparoscopic hernia repair and discharged the next morning. Sutures were placed from the muscular arch to the ileopubic tract, avoiding the spermatic vessels and duct, in an interrupted manner using 2/0-3/0 polypropylene (Prolene®; Ethicon, Somerville, NJ) or polyglactin 910 (Vicryl®; Ethicon) sutures. In 4 cases, a rectangular purse-string-like suture was added to narrow the internal ring defect. Operative findings and postoperative results and complications were assessed. The patients were followed up for a period that ranged between 6 and 60 months. RESULTS: There were 23 boys and 2 girls. Operative age ranged between 18 months and 15 years. Three or four sutures were placed in each case. In 4 cases, an additional rectangular purse-string-like suture was added. Operative time ranged between 35 and 70 minutes, and there was no conversion. Mild scrotal edema was reported in 4 cases and port-site infection in 2 cases; all cases were treated conservatively. One case of recurrence among boys was reported, but there was no case of testicular atrophy. Cosmetic outcomes were excellent. CONCLUSIONS: Laparoscopic interrupted muscular arch repair is a feasible and safe technique in the reconstruction of the inguinal canal in recurrent unilateral PIH. Larger studies and long-term follow-up are needed to support our encouraging results.

Orchiopexy through a single high transverse scrotal incision.

BACKGROUND: Palpable Undescended Testis (PUT) represents a common paediatric problem in many premature and some mature infants. There are several surgical techniques to correct PUT either through combined inguinal and scrotal incision or single transverse scrotal incision. This study assessed single high transverse scrotal incision for the management of PUT as regards to feasibility, postoperative success and final cosmetic results. MATERIALS AND METHODS: One hundred twenty patients were managed at the Paediatric Surgery Department of Tanta University Hospital with PUT during the period from March 2010 to March 2014. They were all operated at the age of 6-12 months. We excluded recurrent cases, and cases older than 12 months. Through high transverse scrotal incision, the layers were divided, and the canal entered through the external ring, dissecting the PUT and bringing it through the incision. Hernia sac, if present, was ligated at the neck. Creation of the dartos pouch was then made through the same incision. All infants were followed-up at 1 month, 2 months and 6 months to detect any re-ascended cases, testicular atrophy and the final cosmetic appearance. RESULTS: A total of 140 PUTs were operated upon in 120 patients. PUT was bilateral in 20 patients, right-sided in 65 cases and left-sided in 35 cases. Thirty testes were located at the external ring; the others were located within the inguinal canal. No cases needed a redo operation, and there was no case of postoperative testicular atrophy. CONCLUSION: Single high transverse incision was sufficient to deal with PUT especially, in young infants (age 6 months) with no need for conversion in most cases to the traditional two incisions technique, and good long term follow-up and a better cosmetic results.