Twenty-year experience with laparoscopic inguinal hernia repair in infants and children: considerations and results on 1833 hernia repairs.

BACKGROUND: The role of laparoscopy in pediatric inguinal hernia (IH) is still controversial. The authors reported their twenty-year experience in laparoscopic IH repair in children. METHODS: In a twenty-year period (1995-2015), we operated 1300 infants and children (935 boys-365 girls) with IH using laparoscopy. The average age at surgery was 18 months (range 7 days-14 years). Body weight ranged between 1.9 and 50 kg (average 9.3). Preoperatively all patients presented a monolateral IH, right-sided in 781 cases (60.1 %) and left-sided in 519 (39.9 %). We excluded patients with bilateral IH and unstable patients in which laparoscopy was contraindicated. If the inguinal orifice diameter was ≥10 mm, we performed a modified purse string suture on peri-orificial peritoneum, in orifices ≤5 mm, we performed a N-shaped suture. RESULTS: No conversion to open surgery was reported. In 533 cases (41 %), we found a contralateral patency of internal inguinal ring that was always closed in laparoscopy. In 1273 cases (97.9 %), we found an oblique external hernia; in 21 cases (1.6 %), a direct hernia; and in 6 cases (0.5 %), a double hernia on the same side (hernia en pantaloon). We found an incarcerated hernia in 27 patients (2 %). Average operative time was 18 min (range 7-65). We recorded 5/1300 recurrences (0.3 %), but in the last 950 patients, we had no recurrence (0 %). We recorded 20 complications (1.5 %): 18 umbilical granulomas and two trocars scar infections, treated in outpatient setting. CONCLUSIONS: On the basis of our twenty-year experience, we prefer to perform IH repair in children using laparoscopy rather than inguinal approach. Laparoscopy is as fast as inguinal approach, and it has the advantage to treat during the same anesthesia a contralateral patency occured in about 40 % of our cases and to treat also rare hernias in about 3 % of cases.

Pediatric anesthesia for minimally invasive surgery in pediatric urology.

Laparoscopic or robotic minimally invasive approaches have become the standard of care for many urological pediatric surgical procedures. Anesthetic concerns for conventional and robotic laparoscopy are similar since they both require insufflations of CO2 to allow visualization of surgical field and perform surgery. Even if required insufflation pressures and volumes are lower in pediatric patients (given the small size of the abdomen and laxity of the abdominal walls), the associated increase of intra-abdominal pressure, along with absorption of CO2 and surgical positioning requirement, may result in neurendocrine and mechanical impact capable to mine cardiopulmonary function. Moreover, laparoscopic approach may require specific positioning. A correct positioning is essential to allow the surgical team to optimally and safely access to the patient. The knowledge of patient's health status, along with the multiple physiologic changes that can occur and specific potential complications, allow the anesthesiologist to provide a safer an aesthesia.