Laparoscopic Hernia Repair with the Extraperitoneal Approach versus Open Hernia Repair in Pediatric Inguinal Hernia: A Systematic Review and Meta-Analysis

Objective: This systematic review and meta-analysis investigated the feasibility and effectiveness of laparoscopic hernia repair with the extraperitoneal approach in pediatric inguinal hernias. Summary Background Data: Inguinal hernia repair is the most common operation in pediatric surgical practice. Although open hernia repair (OHR) is a well-established procedure with good outcomes, studies have reported acceptable or even better outcomes of laparoscopic hernia repair with the extraperitoneal approach (LHRE). However, a meta-analysis comparing LHRE with OHR is lacking. Methods: PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials (RCTs) and comparative studies (prospective or retrospective). Outcomes were metachronous contralateral inguinal hernia (MCIH), hernia recurrence, surgical site infection, operation time, and hospitalization length. A meta-analysis was performed, and risk ratios (RR), weighted mean difference (WMD), and 95% confidence intervals (CI) were calculated using random-effects models. Results: Five RCTs and 21 comparative studies involving 24,479 patients were included. Lower MCIH incidence (RR: 0.11, 95% CI: 0.07 to 0.17; p < 0.00001) and a trend of shorter operation time (WMD: −11.90 min, 95% CI: −16.63 to −7.44; p < 0.00001) were found in the LHRE group. No significant differences in ipsilateral recurrence hernias, surgical site infection, and length of hospitalization were found between the groups. Conclusions: LHRE presented lower MCIH incidence and shorter operation times, with no increase in hernia recurrence, surgical site infection, or length of hospitalization. As more surgeons are increasingly becoming familiar with LHRE, LHRE would be a feasible and effective choice for pediatric inguinal hernia repair.

Comparison of Laparoscope-Assisted Single-Needle Laparoscopic Percutaneous Extraperitoneal Closure versus Open Repair for Pediatric Inguinal Hernia

Background: Laparoscopic repairs have gained gradual acceptance in pediatric inguinal hernia over the past decade. However, consensus about the optimal management is still lacking. The aim of this study is to present a modified single-needle laparoscopic approach with the assistance of a laparoscope and to evaluate the surgical outcomes in comparison with traditional open repair method. Materials and Methods: We retrospectively reviewed the medical data of children who underwent laparoscope-assisted single-needle laparoscopic percutaneous extraperitoneal closure (LPEC) and open repair (OR) for inguinal hernia from 2014 to 2019. Data were reviewed and analyzed with respect to the operating time, the incidence of metachronous contralateral inguinal hernia (MCIH), recurrence, and other complications. Results: In our cohort, 961 patients in the OR group and 1098 patients in the LPEC group were analyzed retrospectively. Mean operative time was significantly shorter in the LPEC group (22.3±3.5 min) than in the OR group (27.8±5.9 min) for bilateral hernia repair (p<0.001). Iatrogenic cryptorchidism occurred statistically more frequently in the OR group than in the LPEC group (0.4% vs. 0%, p=0.013). In addition, the incidence of MCIH was 3.7% (33/887) in the OR group and 0.3% (3/1014) in the LPEC group (p<0.01). Conclusion: Based on the current outcomes, laparoscope-assisted single-needle LPEC provides a simple and attractive option for the administration of pediatric patients with inguinal hernia/hydrocele to reduce the MCIH.

Modification of the Classical Percutaneous Extraperitoneal Procedure for Pediatric Inguinal Hernia to Reduce Complications: A Multiple-Centered Comparison Study

Single-site laparoscopic percutaneous extraperitoneal ligation (SLPEL) for pediatric inguinal hernia gained popularity all over the world. However, complications associated with extraperitoneal knotting were not rare in the classical SLPEL(C-SLPEL) procedure. In order to overcome disadvantages, we herein developed the modified SLPEL (M-SLPEL) procedure, intact circuit ligation of the peritoneum around the internal ring using a homemade hernia needle with a single abdominal wall centesis. To evaluated the effectiveness of the M-SLPEL procedure to decrease adverse events associated with ligation knotting, a comparative study was carried out. A total of 3219 patients from multiple centers were divided into two groups according to the operative procedures: M-SLPEL group and C-SLPEL group. All patients were followed up. Data describing the clinical characteristics, operative time, postoperative hospital stay, and complications was collected and retrospectively analyzed. With equivalent operative time, postoperative hospital stay, there was statistically significant difference between two groups in terms of the overall complications incidence (2.6% in C-SLPEL Vs 0.11% in M-SLPEL, P=0.03), including pain in inguinal area, knot foreign body reaction, palpable knot, recurrence. Together, these findings suggest that the M-SLPEL procedure is an effective and safe approach, with unique advantage in reducing adverse events in the inguinal region.