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Laparoscopic treatment of congenital inguinal hernia in children
Laparoscopic
Treatment
of Congenital
By Philippe
Montupet
Inguinal
and
Ciro
Paris, France and Napoli,
Purpose: The authors report scopic treatment of congenital
their experience inguinal hernia
in the laparoin children.
Methods: Between September 1994 and September 1995,45 boys between 8 months and 13 years of age (mean, 4 years) were treated laparoscopically for hydroceles, spermatic cord cysts, or hernias. Twenty-six (57.8%) boys showed a right inguinal hernia, 17 (37.8%) a left hernia, and two cases (4.4%) presented the clinical data of a bilateral pathology. The approach used for small hernias was the placement of purse-string suture around the internal orifice of the inguinal canal (28 cases). As to hernias exceeding 4 to 5 mm in diameter, the external hemicircumference of the neck was opened to bring the conjoined tendon closer to the crural arch with a nonresorbable suture (17 cases). There was never need to use a prosthesis.
I
NGUINAL HERNIAS in children most often are found in the simple opening of the peritoneal vaginal canal (PVC); however, they always require surgical treatment for the definitive occlusion of the orifice. This is generally done with a traditional surgical approach. In girls it can be achieved without any complications, whereasin boys it needsto be performed after separating important elementsof the cord and peritoneum, and with a high ligation of the latter.’ This simple surgical procedure, which has given successful results in the treatment of hernias, hydroceles, and cord cysts, has a relatively low incidence of complication, These can be minor, parietal, or severe, the latter negatively affecting testicular trophism and fertility.2%3 The controlateral accessroute is not systematic. For this reason some children need to undergo surgery a secondtime for an undetected hernia. Lastly, in case of recurrence, repeatedsurgery of the cord is not devoid of risks.4J MATERIALS
AND
METHODS
Between September 1994 and September 199.5 we used laparoscopy to treat 45 openings of the processus vagindis canal in boys aged 8
From the Centre Chirurgicale Boulogne Billancourt, Paris, France, and the Division of Pediatric Surgery *) University of Naples, Italy. Address reprint requests to Ciro Esposito, MD, Division of Pediatric Surgery, <
Hernia
in Children
Esposito
Italy
Results: Surgery lasted from 15 to 45 minutes with the duration decreasing with experience. There were no intra- or postsurgical complications. Two patients (4.4%) experienced a recurrent inguinal hernia, which was successfully operated on again with laparoscopy. Conclusion: The early results of these authors suggest that laparoscopic surgery is a feasible and safe technique for the treatment of patent peritoneal vaginal canal (PVC) and inguinal hernia in children. J Pediafr Surg 34:420-423. Copyright o 1999 by W.B. Saunders Company.
INDEX
WORDS:
lnguinal
hernia,
laparoscopy.
months or older. Our decision not to operate before the age of 8 months depended on the choice of our team of anestheticians, who prefer to avoid performing a laparoscopy on younger patients if the intervention is to be performed on a day-hospital basis. This case series of 45 consecutive patients is part of a larger series of 201 patients who underwent surgery for the same pathology between April 1993 and September 1997. The subsample of 45 children was examined to ensure their compliance with the two selection criteria that the authors decided to adopt to evaluate the new technique. First, all patients who had undergone surgery between April 1993 and September 1994 were excluded to account for the learning curve, ie, the time needed to master this new technique; second, it was decided to have at least 2 years of follow-up per patient to detect possible recurrent hernias. All 45 boys, who were aged between 8 months and 13 years (mean, 4 years), were affected by hydroceles, spermatic cord cysts, or hernia. Twenty-six (57.8%) boys showed a right inguinal hernia, 17 (37.8%) a left hernia, and in two cases (4.4%) the clinical data showed bilateral pathology. Three boys had an inguinal hernia recurrent to conventional surgery, and 1 boy presented a contralateral hernia after surgery on a monolateral hernia. None of the patients in this case series had an incarcerated hernia. This simple technique requires an intraabdominal pressure between 5 and 8 mm Hg. All children had general anesthesia with orotracheal intubation. A 0” 5-mm telescope was inserted through the umbilicus and two 3-mm trocars were placed 3 to 4 cm below the umbilicus at the level of the left and right side, the exact positions of the two 3-mm ports depending on the child’s age. Our approach to small hernias is to place purse-string sutures of 3-O resorbable suture around the internal orifice of the inguinal canal (28 cases, Figs 1 and 2). Before performing the purse-string suture, it is preferable to cut the periorificial peritoneum laterally to the internal inguinal rin g, because this facilitates this type of suture and the closure of the distal part of the PVC. As for hernias exceeding 4 to 5 mm in diameter, after opening the periorificial peritoneum and performing the purse-string suture at the level of the internal inguinal orifice, we bring the internal inguinal ring Journal
ofPediatric
Surgery,
Vol34,
No 3 (March),
1999:
pp 420-423
LAPAROSCOPIC
Fig 1.
TREATMENT
Laproscopic
OF CONGENITAL
aspect
of a right
421
HERNIA
inguinal
hernia Fig 3. intervention.
to a smaller diameter by placing one or more detached sutures with nonabsorbable suture between the conjoined tendon and the crural arch (17 cases). We have never used a prosthesis as in laparoscopic correction of inguinal hernias in adults. In six patients (13.3%) who showed clinical evidence of monolateral inguinal hernia, we performed the closure of the contralateral peritoneal vaginal canal that was opened; this was done with a purse-string suture at the level of the internal inguinal ring (Fig 3).
RESULTS
Surgery lastedfrom 1.5to 45 minutes,with the duration decreasing with experience. There were no intra- or postsurgical complications in this case series of 45 patients. As to the seriesof 201 caseswe have operated with this technique, there were no intra- or postsurgical complications. An important characteristic of the laparoscopic approach is that it leaves a very small scar and requires a very short hospital stay, aswith traditional surgery.Every patient was seenagainwithin the first 6 months and then
Fig 2. A purse-string the inguinal canal.
suture
around
the
internal
opening
orifice
of
The
appearance
of closed
inguinal
orifice
at the
end
of
after 2 years to evaluate both efficacy and reliability of the technique. In 43 patients (95.6%) there was a total recovery from the hernia, in two patients (4.4%) there was a recurrence on the sameside at 6 and 12 months from the laparoscopic intervention. Thesetwo patientsunderwentlaparoscopicsurgery a secondtime, which evidenced a repermeabilization of the vaginal peritoneal duct. The surgical report indicated the presenceof a large internal inguinal opening in both cases;during the first operation, in neither case was any suture positioned between the conjoined tendon and the crural arch. A two-plane laparoscopicalreparation was performed successfully, and these results were evident also at a 12-month follow-up in both patients. DISCUSSION
Inguinal hernia repair is one of the most common operationsperformed in children. As shownby the results in this series,this operation has a high successrate and a low complication rate.6,7However, its treatment is still controversial becauseof three main aspects:the exploration of the asymptomatic contralateral side,the incidence of complicationsrelated to the possibledamageof the vas deferensor the spermatic vessels,and the complications related to the surgical technique, such as recurrencesof hernia or iatrogenic cryptorchidism.*-lo Moreover, traditional inguinal hernia repair is not devoid of other complications. Nerve entrapment by a suture or nerve sectioning (ilioinguinal, iliohypogastric branches)may result in prolonged discomfort, pain, or dysanasthesia.“.12Given the possibility of the development of contralateral hernia in a relatively high percentage of patients soon after unilateral repair, some senior pediatric surgeonsin the United Statesprefer to perform
422
MONTUPET
bilateral approaches in both sexes8z9 Several investigators have acknowledged that routine bilateral exploration would disclose a contralateral sac in about 50% to 90% of cases (>89% in the first year of life), but contend that only a small percentage of these sacs (5.6% to 16%) would evolve into clinical hemias.‘O-l3 Furthermore, possible testicle damage with routine bilateral exploration is a serious consideration that has been made. Atrophy of the testis has been reported in at least 1% of the patients operated on for inguinal hernia, and some diminution in testis size has been observed in an additional 2.7%.7,11,14J5 In addition, the risk of damaging the vas and testicle is considerably greater in cases in which the surgeon searches for a small or a nonexistent hernial sac during routine bilateral exploration.16 Sparkman12 states that even among competent surgeons, there may be a 1.6% incidence of inadvertent removal of a segment of the vas deferens with the hernia sac. Moreover, other risks related to the traditional inguinal exploration include iatrogenic ascent of the testis, wound infection, and recurrences.17,18 The incidence of these complications is often underestimated, especially because the follow-up of a patient who has undergone surgery for an inguinal hernia is rather short, whereas these complications occur much later and may be casually detected during adolescence. For all these reasons, 3 years ago we began to adopt the laparoscopic approach to treat boys affected by patency of the peritoneal vaginal duct. The advantages expected from this technique are the opportunity to evaluate the contralateral side and the elimination of complications from wall and cord lesions.19-23 In case of laparoscopic evidence of contralateral permeability of the processus vaginalis, it is possible to perform a bilateral closure of both the deep inguinal orifice and periorificial peritoneum by protracting the surgical act by only 5 to 10 minutes without the need for additional trocars. Furthermore, our procedure allows the surgeon to lift with a grasper the peritoneal sheet situated around the inner inguinal ring, because, as we demonstrated, it may conceal the permeability of PVC.
AND
ESPOSITO
In case of hernial recurrences after a traditional inguinal approach, with the laparoscopic technique there is no need for another dissection of the cord; in addition it shows the possible presence of a direct hernia, as happened in two patients of our series. However, the most important advantage when dealing with a recurrent inguinal hernia is the possibility to work on virgin structures of the internal inguinal orifice rather than on scar tissue, as happens when adopting the inguinal approach for the second time on the same side. We believe that the two recurrences of our series were caused by the very large internal inguinal orifice left open. In case of a wide internal inguinal opening, it is important to close the large internal inguinal ring with nonresorbable suture to approach the conjoint tendon to the crural arch and, thereafter, to close the periorificial peritoneum, thus obtaining a two-plane closure. The complications strictly related to the laparoscopic technique are practically eliminated with the routine use of the open approach for the introduction of the first trocar; moreover, this technique does not require coagulation, thus decreasing the risks related to monopolar coagulation. However, it is clear that this technique must be performed by an expert laparoscopist who is capable of manipulating the needle and who can place the intracorporeal sutures without problems. The laparoscopy requires the same operating time as conventional surgery in cases of unilateral inguinal hernia, but may be even faster in cases of bilateral inguinal hernia; as conventional surgery, the postoperative course is painless and very short. Considering the 5.6% to 16% chances for children with monolateral pathology to develop a contralateral inguinal hernia after some time, the advantage of the laparoscopy is that it resolves the problem bilaterally at once, thus doing away with the need for a second operation (and thus anesthesia), and reducing both economic impact and risks to the patient. We believe that the technique described here is an effective and reliable therapy. In some conditions, such as recurrent inguinal hernias, it represents a valid alternative to traditional surgery.
REFERENCES 1. Potts WJ, Riker WL, Lewis JE: The treatment of inguinal hernia in infants and children. Ann Sug 132566-576, 1950 2. Rothemberg RE, Bamett T: Bilateral hemiotomy in infants and children. Surgery 37:947-950. 1955 3. Zhang JZ, Li XZ: Inguinal hernia in infants and children in China. Pediatr Surg Int 8:458-461, 1993 4. Kiesewetter WB, Sang Oh K: Unilateral inguinal hernias in children. What about the opposite side? Arch Surg 115: 1443-1445,198O 5. McGregor DB, Halverson K, McVay CB: The unilateral pediatric inguinal hernia: Should the contralateral side be explored? J Pediatr Surg 15:313-317. 1980
6. Chatterjee SK: Inguinal hernia. Pediatr Surg Int 8453-454, 1993 7. Schmitt M, Peiffert B, de Miscault G, et al: Les complications de la hemie inguinale chez le gaqon. Chir Pediatr 28193-196, 1987 8. Gilbert M, Clatwotthy Hw: Bilateral operations for inguinal hernia and hydrocele in infancy and childhood. Am J Stag 97:255-259,1959 9. Tepas III JJ, Stafford PW: Timing of automatic contralateral groin exploration in male infants with unilateral hernias. Am Surg 52:70-71, 1986 10. Grosfeld JL, Minnick K, Shedd F, et al: Inguinal hernia in children: Factors affecting recurrence in 62 cases. J Pediatr Surg 26:283-287, 1991
LAPAROSCOPIC
TREATMENT
OF CONGENITAL
HERNIA
11. Rathauser F: Historical overview of the bilateral approach to pediatric inguinal hernias. Am J Surg 150:527-532, 1985 12. Sparkman RS: Bilateral exploration in inguinal hernia in juvenile patients. Surgery 51:393-406, 1962 13. Melone JH, Schwartz MZ, Tyson KRT, et al: Outpatient inguinal herniotrhaphy in premature infants: Is it safe? J Pediatr Surg 27:203208. 1992 14. Surana R, Pm-i P: Is contralateral exploration necessary in infants with unilateral inguinal hernia? J Pediatr Surg 28:1026-1027, 1993 15. Muraji T, Noda T, Higashimoto Y, et al: Contralateral incidence after repair of unilateral inguinal hernia in infants and children. Pediatr Surg Int 8:455-457, 1993 16. Janik JS, Shandling B: The vulnerability of the vas deferens(I1): The case against routine bilateral inguinal exploration. J Pediatr Surg 17:585-588, 1982 17. Audry G, Johanet S, Achrafi H, et al: The risk of wound infection after inguinal incision in pediatric outpatient surgery. Eur J Pediatr Surg 4:87-89, 1994
423
18. Kaplan GW: Iatrogenic cryptorchidism resulting from hernia repair. Surg Gynecol Obstet 142:671-672: 1976 19. Misra D, Hewitt G, Potts SR, et al: Transperitoneal closure of internal ring in incarcerated infantile inguinal hernias. J Pediatr Surg 30:95-96, 1995 20. Holcomb III GW, Brock III JW, Morgan III WM: Laparoscopic evaluation for a contralateral patent processus vaginalis. J Pediatr Surg 29:970-974, 1994 21. Grossmann PA, Wolf SA, Hopkins JW, et al: The efficacy of laparoscopic examination of the internal inguinal ring in children. J Pediatr Surg 30214-218, 1995 22. Stylianos S, Jacir NN, Harris BH: Incarceration of inguinal hernia in infants prior to elective repair. J Pediatr Surg 28:582-583, 1993 23. Lobe TE: Inguinal hernias in pediatrics: Initial experience with laparoscopic inguinal exploration of the asymptomatic contralateral side. J Laparoendosc Surg 2:135-140, 1992
Treatment
of Congenital
By Philippe
Montupet
Inguinal
and
Ciro
Paris, France and Napoli,
Purpose: The authors report scopic treatment of congenital
their experience inguinal hernia
in the laparoin children.
Methods: Between September 1994 and September 1995,45 boys between 8 months and 13 years of age (mean, 4 years) were treated laparoscopically for hydroceles, spermatic cord cysts, or hernias. Twenty-six (57.8%) boys showed a right inguinal hernia, 17 (37.8%) a left hernia, and two cases (4.4%) presented the clinical data of a bilateral pathology. The approach used for small hernias was the placement of purse-string suture around the internal orifice of the inguinal canal (28 cases). As to hernias exceeding 4 to 5 mm in diameter, the external hemicircumference of the neck was opened to bring the conjoined tendon closer to the crural arch with a nonresorbable suture (17 cases). There was never need to use a prosthesis.
I
NGUINAL HERNIAS in children most often are found in the simple opening of the peritoneal vaginal canal (PVC); however, they always require surgical treatment for the definitive occlusion of the orifice. This is generally done with a traditional surgical approach. In girls it can be achieved without any complications, whereasin boys it needsto be performed after separating important elementsof the cord and peritoneum, and with a high ligation of the latter.’ This simple surgical procedure, which has given successful results in the treatment of hernias, hydroceles, and cord cysts, has a relatively low incidence of complication, These can be minor, parietal, or severe, the latter negatively affecting testicular trophism and fertility.2%3 The controlateral accessroute is not systematic. For this reason some children need to undergo surgery a secondtime for an undetected hernia. Lastly, in case of recurrence, repeatedsurgery of the cord is not devoid of risks.4J MATERIALS
AND
METHODS
Between September 1994 and September 199.5 we used laparoscopy to treat 45 openings of the processus vagindis canal in boys aged 8
From the Centre Chirurgicale Boulogne Billancourt, Paris, France, and the Division of Pediatric Surgery *
Hernia
in Children
Esposito
Italy
Results: Surgery lasted from 15 to 45 minutes with the duration decreasing with experience. There were no intra- or postsurgical complications. Two patients (4.4%) experienced a recurrent inguinal hernia, which was successfully operated on again with laparoscopy. Conclusion: The early results of these authors suggest that laparoscopic surgery is a feasible and safe technique for the treatment of patent peritoneal vaginal canal (PVC) and inguinal hernia in children. J Pediafr Surg 34:420-423. Copyright o 1999 by W.B. Saunders Company.
INDEX
WORDS:
lnguinal
hernia,
laparoscopy.
months or older. Our decision not to operate before the age of 8 months depended on the choice of our team of anestheticians, who prefer to avoid performing a laparoscopy on younger patients if the intervention is to be performed on a day-hospital basis. This case series of 45 consecutive patients is part of a larger series of 201 patients who underwent surgery for the same pathology between April 1993 and September 1997. The subsample of 45 children was examined to ensure their compliance with the two selection criteria that the authors decided to adopt to evaluate the new technique. First, all patients who had undergone surgery between April 1993 and September 1994 were excluded to account for the learning curve, ie, the time needed to master this new technique; second, it was decided to have at least 2 years of follow-up per patient to detect possible recurrent hernias. All 45 boys, who were aged between 8 months and 13 years (mean, 4 years), were affected by hydroceles, spermatic cord cysts, or hernia. Twenty-six (57.8%) boys showed a right inguinal hernia, 17 (37.8%) a left hernia, and in two cases (4.4%) the clinical data showed bilateral pathology. Three boys had an inguinal hernia recurrent to conventional surgery, and 1 boy presented a contralateral hernia after surgery on a monolateral hernia. None of the patients in this case series had an incarcerated hernia. This simple technique requires an intraabdominal pressure between 5 and 8 mm Hg. All children had general anesthesia with orotracheal intubation. A 0” 5-mm telescope was inserted through the umbilicus and two 3-mm trocars were placed 3 to 4 cm below the umbilicus at the level of the left and right side, the exact positions of the two 3-mm ports depending on the child’s age. Our approach to small hernias is to place purse-string sutures of 3-O resorbable suture around the internal orifice of the inguinal canal (28 cases, Figs 1 and 2). Before performing the purse-string suture, it is preferable to cut the periorificial peritoneum laterally to the internal inguinal rin g, because this facilitates this type of suture and the closure of the distal part of the PVC. As for hernias exceeding 4 to 5 mm in diameter, after opening the periorificial peritoneum and performing the purse-string suture at the level of the internal inguinal orifice, we bring the internal inguinal ring Journal
ofPediatric
Surgery,
Vol34,
No 3 (March),
1999:
pp 420-423
LAPAROSCOPIC
Fig 1.
TREATMENT
Laproscopic
OF CONGENITAL
aspect
of a right
421
HERNIA
inguinal
hernia Fig 3. intervention.
to a smaller diameter by placing one or more detached sutures with nonabsorbable suture between the conjoined tendon and the crural arch (17 cases). We have never used a prosthesis as in laparoscopic correction of inguinal hernias in adults. In six patients (13.3%) who showed clinical evidence of monolateral inguinal hernia, we performed the closure of the contralateral peritoneal vaginal canal that was opened; this was done with a purse-string suture at the level of the internal inguinal ring (Fig 3).
RESULTS
Surgery lastedfrom 1.5to 45 minutes,with the duration decreasing with experience. There were no intra- or postsurgical complications in this case series of 45 patients. As to the seriesof 201 caseswe have operated with this technique, there were no intra- or postsurgical complications. An important characteristic of the laparoscopic approach is that it leaves a very small scar and requires a very short hospital stay, aswith traditional surgery.Every patient was seenagainwithin the first 6 months and then
Fig 2. A purse-string the inguinal canal.
suture
around
the
internal
opening
orifice
of
The
appearance
of closed
inguinal
orifice
at the
end
of
after 2 years to evaluate both efficacy and reliability of the technique. In 43 patients (95.6%) there was a total recovery from the hernia, in two patients (4.4%) there was a recurrence on the sameside at 6 and 12 months from the laparoscopic intervention. Thesetwo patientsunderwentlaparoscopicsurgery a secondtime, which evidenced a repermeabilization of the vaginal peritoneal duct. The surgical report indicated the presenceof a large internal inguinal opening in both cases;during the first operation, in neither case was any suture positioned between the conjoined tendon and the crural arch. A two-plane laparoscopicalreparation was performed successfully, and these results were evident also at a 12-month follow-up in both patients. DISCUSSION
Inguinal hernia repair is one of the most common operationsperformed in children. As shownby the results in this series,this operation has a high successrate and a low complication rate.6,7However, its treatment is still controversial becauseof three main aspects:the exploration of the asymptomatic contralateral side,the incidence of complicationsrelated to the possibledamageof the vas deferensor the spermatic vessels,and the complications related to the surgical technique, such as recurrencesof hernia or iatrogenic cryptorchidism.*-lo Moreover, traditional inguinal hernia repair is not devoid of other complications. Nerve entrapment by a suture or nerve sectioning (ilioinguinal, iliohypogastric branches)may result in prolonged discomfort, pain, or dysanasthesia.“.12Given the possibility of the development of contralateral hernia in a relatively high percentage of patients soon after unilateral repair, some senior pediatric surgeonsin the United Statesprefer to perform
422
MONTUPET
bilateral approaches in both sexes8z9 Several investigators have acknowledged that routine bilateral exploration would disclose a contralateral sac in about 50% to 90% of cases (>89% in the first year of life), but contend that only a small percentage of these sacs (5.6% to 16%) would evolve into clinical hemias.‘O-l3 Furthermore, possible testicle damage with routine bilateral exploration is a serious consideration that has been made. Atrophy of the testis has been reported in at least 1% of the patients operated on for inguinal hernia, and some diminution in testis size has been observed in an additional 2.7%.7,11,14J5 In addition, the risk of damaging the vas and testicle is considerably greater in cases in which the surgeon searches for a small or a nonexistent hernial sac during routine bilateral exploration.16 Sparkman12 states that even among competent surgeons, there may be a 1.6% incidence of inadvertent removal of a segment of the vas deferens with the hernia sac. Moreover, other risks related to the traditional inguinal exploration include iatrogenic ascent of the testis, wound infection, and recurrences.17,18 The incidence of these complications is often underestimated, especially because the follow-up of a patient who has undergone surgery for an inguinal hernia is rather short, whereas these complications occur much later and may be casually detected during adolescence. For all these reasons, 3 years ago we began to adopt the laparoscopic approach to treat boys affected by patency of the peritoneal vaginal duct. The advantages expected from this technique are the opportunity to evaluate the contralateral side and the elimination of complications from wall and cord lesions.19-23 In case of laparoscopic evidence of contralateral permeability of the processus vaginalis, it is possible to perform a bilateral closure of both the deep inguinal orifice and periorificial peritoneum by protracting the surgical act by only 5 to 10 minutes without the need for additional trocars. Furthermore, our procedure allows the surgeon to lift with a grasper the peritoneal sheet situated around the inner inguinal ring, because, as we demonstrated, it may conceal the permeability of PVC.
AND
ESPOSITO
In case of hernial recurrences after a traditional inguinal approach, with the laparoscopic technique there is no need for another dissection of the cord; in addition it shows the possible presence of a direct hernia, as happened in two patients of our series. However, the most important advantage when dealing with a recurrent inguinal hernia is the possibility to work on virgin structures of the internal inguinal orifice rather than on scar tissue, as happens when adopting the inguinal approach for the second time on the same side. We believe that the two recurrences of our series were caused by the very large internal inguinal orifice left open. In case of a wide internal inguinal opening, it is important to close the large internal inguinal ring with nonresorbable suture to approach the conjoint tendon to the crural arch and, thereafter, to close the periorificial peritoneum, thus obtaining a two-plane closure. The complications strictly related to the laparoscopic technique are practically eliminated with the routine use of the open approach for the introduction of the first trocar; moreover, this technique does not require coagulation, thus decreasing the risks related to monopolar coagulation. However, it is clear that this technique must be performed by an expert laparoscopist who is capable of manipulating the needle and who can place the intracorporeal sutures without problems. The laparoscopy requires the same operating time as conventional surgery in cases of unilateral inguinal hernia, but may be even faster in cases of bilateral inguinal hernia; as conventional surgery, the postoperative course is painless and very short. Considering the 5.6% to 16% chances for children with monolateral pathology to develop a contralateral inguinal hernia after some time, the advantage of the laparoscopy is that it resolves the problem bilaterally at once, thus doing away with the need for a second operation (and thus anesthesia), and reducing both economic impact and risks to the patient. We believe that the technique described here is an effective and reliable therapy. In some conditions, such as recurrent inguinal hernias, it represents a valid alternative to traditional surgery.
REFERENCES 1. Potts WJ, Riker WL, Lewis JE: The treatment of inguinal hernia in infants and children. Ann Sug 132566-576, 1950 2. Rothemberg RE, Bamett T: Bilateral hemiotomy in infants and children. Surgery 37:947-950. 1955 3. Zhang JZ, Li XZ: Inguinal hernia in infants and children in China. Pediatr Surg Int 8:458-461, 1993 4. Kiesewetter WB, Sang Oh K: Unilateral inguinal hernias in children. What about the opposite side? Arch Surg 115: 1443-1445,198O 5. McGregor DB, Halverson K, McVay CB: The unilateral pediatric inguinal hernia: Should the contralateral side be explored? J Pediatr Surg 15:313-317. 1980
6. Chatterjee SK: Inguinal hernia. Pediatr Surg Int 8453-454, 1993 7. Schmitt M, Peiffert B, de Miscault G, et al: Les complications de la hemie inguinale chez le gaqon. Chir Pediatr 28193-196, 1987 8. Gilbert M, Clatwotthy Hw: Bilateral operations for inguinal hernia and hydrocele in infancy and childhood. Am J Stag 97:255-259,1959 9. Tepas III JJ, Stafford PW: Timing of automatic contralateral groin exploration in male infants with unilateral hernias. Am Surg 52:70-71, 1986 10. Grosfeld JL, Minnick K, Shedd F, et al: Inguinal hernia in children: Factors affecting recurrence in 62 cases. J Pediatr Surg 26:283-287, 1991
LAPAROSCOPIC
TREATMENT
OF CONGENITAL
HERNIA
11. Rathauser F: Historical overview of the bilateral approach to pediatric inguinal hernias. Am J Surg 150:527-532, 1985 12. Sparkman RS: Bilateral exploration in inguinal hernia in juvenile patients. Surgery 51:393-406, 1962 13. Melone JH, Schwartz MZ, Tyson KRT, et al: Outpatient inguinal herniotrhaphy in premature infants: Is it safe? J Pediatr Surg 27:203208. 1992 14. Surana R, Pm-i P: Is contralateral exploration necessary in infants with unilateral inguinal hernia? J Pediatr Surg 28:1026-1027, 1993 15. Muraji T, Noda T, Higashimoto Y, et al: Contralateral incidence after repair of unilateral inguinal hernia in infants and children. Pediatr Surg Int 8:455-457, 1993 16. Janik JS, Shandling B: The vulnerability of the vas deferens(I1): The case against routine bilateral inguinal exploration. J Pediatr Surg 17:585-588, 1982 17. Audry G, Johanet S, Achrafi H, et al: The risk of wound infection after inguinal incision in pediatric outpatient surgery. Eur J Pediatr Surg 4:87-89, 1994
423
18. Kaplan GW: Iatrogenic cryptorchidism resulting from hernia repair. Surg Gynecol Obstet 142:671-672: 1976 19. Misra D, Hewitt G, Potts SR, et al: Transperitoneal closure of internal ring in incarcerated infantile inguinal hernias. J Pediatr Surg 30:95-96, 1995 20. Holcomb III GW, Brock III JW, Morgan III WM: Laparoscopic evaluation for a contralateral patent processus vaginalis. J Pediatr Surg 29:970-974, 1994 21. Grossmann PA, Wolf SA, Hopkins JW, et al: The efficacy of laparoscopic examination of the internal inguinal ring in children. J Pediatr Surg 30214-218, 1995 22. Stylianos S, Jacir NN, Harris BH: Incarceration of inguinal hernia in infants prior to elective repair. J Pediatr Surg 28:582-583, 1993 23. Lobe TE: Inguinal hernias in pediatrics: Initial experience with laparoscopic inguinal exploration of the asymptomatic contralateral side. J Laparoendosc Surg 2:135-140, 1992