Hernia DOI 10.1007/s10029-014-1269-x
ORIGINAL ARTICLE
Neonatal laparoscopic inguinal hernia repair: a 3-year experience V. Pastore • F. Bartoli
Received: 24 November 2013 / Accepted: 23 May 2014 Ó Springer-Verlag France 2014
Abstract Purpose To retrospectively analyze the feasibility, safety and complication rate of laparoscopic inguinal herniorraphy in babies weighing 5 kg or less. Methods Thirty infants weighing 5 kg or less underwent laparoscopic inguinal hernia repair during a 3-year period. Twenty-eight infants were born preterm and the mean body weight at surgery was 3,800 kg. Internal inguinal ring was closed with a non-absorbable purse-string suture. Contralateral processus vaginalis was closed if patent. Feeding was started on the same day and the patient discharged the following day. Follow-up consisted of physical examination at 1 week, 6 and 12 months postoperatively. Results Of the 30 patients (27 males, 3 females), 11 had bilateral and 19 monolateral hernia (16 right, 3 left). At laparoscopy, 23 infants needed to have bilateral herniorraphies. The mean corrected gestational age at surgery was 49.1 weeks. The mean operative time for repair was 30 min for unilateral and 41 min for bilateral hernia. There were not intra- or post-operative complications as well as conversions or recurrences. Conclusions Laparoscopic inguinal hernia repair in newborns and in ex-preterm infants is a safe and effective procedure to perform and, perhaps, even less technically demanding than open herniotomy.
V. Pastore (&) F. Bartoli Pediatric Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto 1, 71122 Foggia, Italy e-mail: [email protected]
Keywords Inguinal hernia Laparoscopy Newborn Preterm-infant
Introduction Inguinal hernia (IH) is a common condition requiring surgical repair in the pediatric age group. Its incidence is 3–5 % in term and 13 % in preterm infants (\36 weeks of gestational age) [1]. Open herniotomy is the standard procedure against which all other alternatives have to be compared. During the last decade, laparoscopic IH repair has become a routine procedure in older children but its use in neonates and premature babies is still limited [2– 5]. Reported advantages of laparoscopic hernia repair include excellent visual exposure, minimal dissection of vas deferens and spermatic vessels, fewer complications, comparable recurrence rates, and improved cosmetic results compared with the traditional open approach [6]. In addition, laparoscopic hernia approach allows diagnosis and repair of contralateral patent processus vaginalis (PPV), uncommon types of hernias (es. femoral, direct, combined hernia) and recurrent or complicated hernia [7, 8]. During the first year of life, the probability of finding a PPV on the contralateral side may be up to 50 % of cases [9] and the incidence of metachronous hernia ranges from 1 to 38 % as attested in different studies [10]. Recently, few authors have reported successful treatment of these infants through laparoscopy. Furthermore, the timing of IH repair in infants—early or delayed—is still a matter of discussion. The purpose of this study has been to retrospectively analyze the feasibility, safety, and complication rate of laparoscopic inguinal herniorraphy in babies weighing 5 kg or less.
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Hernia
Operative technique
placement of the stitch on the lateral and inferior border of PPV (Fig. 3). The suture proceeds on inferior margin and is completed by stitching the peritoneum on lateral and superior margin (Figs. 4, 5). This procedure avoids obstruction of vas and spermatic vessels because they lie in the retroperitoneal space. The contralateral processus vaginalis was examined for patency and it was closed in the same manner without the need to change the trocar positions. We consider PPV if a 3-mm Kelly forceps can be introduced into the processus vaginalis for a length of at least 1 cm (the length of the opening jaws). The needle was extracted transparietally, in the same way as the insertion and the incisions closed. Feeding was started on the same day of the procedure and the patient discharged on the first post-operative day. Follow-up consisted in clinical
All surgical procedures were performed with the neonate in a supine position under general anesthesia using tracheal intubation. A 5-mm 0° laparoscope was placed through the umbilical port by open Hasson’s technique to minimize the risk for bowel injury. Two further 3 mm working instruments were placed at right and left lower quadrant of the abdomen. Pneumoperitoneum was kept at a pressure of 6–8 mmHg to avoid ventilation problems during surgery. A 4–0 non-absorbable monofilamentous suture was inserted directly through the abdominal wall next to the internal inguinal ring and PPV was closed with a purse-string suture at level of the internal inguinal ring. The purse-string suture is placed on the peritoneum by starting from the level of medial and superior margin of the internal inguinal ring as suggested by several authors [7, 11] (Fig. 1). Then, the peritoneum between vas and spermatic vessels is carefully lifted with the help of grasper (to protect spermatic cord structure) (Fig. 2) for a better and safer
Fig. 2 The peritoneum between vas and spermatic vessels is carefully lifted with the help of grasper
Fig. 1 Open left internal inguinal ring and first stitch on medial and superior margin
Fig. 3 Placement of the stitch on the lateral and inferior border of left PPV
Methods Patients We reviewed the charts of 30 infants with IH weighing \5 kg who underwent laparoscopic repair at our institution over a 3-year period. All the patients were operated by the same senior author. The mean body weight at surgery was 3,800 kg (range 1,900–5,000 kg) and 28 out of 30 patients (93 %) were premature born \36 weeks’ gestation. Laparoscopic IH repair was carried out when the babies were older than 45 corrected weeks’ gestation or when they reached 2,100 kg.
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Hernia
incarcerated IH, but only one was treated earlier (when its body weight was still 1,900 kg) because of repeated incarceration episodes. The mean operative time for hernia repair was 30 min (range 20–35) for unilateral and 39 min (range 26–51) for bilateral IH. There were no intra- or postoperative complications or need for conversion. No patient suffered apnea episodes after the procedure. All the babies started feeding on the same day of surgery and all were discharged from the hospital the day after. No recurrences or metachronous IH were detected at a mean follow-up of 21 months (range 6–40). Cosmesis was excellent and no wound infection was found. Four boys had undescended testis before surgery (2 bilateral and 2 monolateral) but only 3 of them required subsequent orchiopexy at 10 months of age. Fig. 4 The purse-string suture ends at superior and lateral margin of left ring
Fig. 5 Final view of the closed left internal inguinal ring with nonabsorbable suture
evaluation at 1 week, 6 months and 1 year. For this study’s purpose a phone interview was done about clinical outcome.
Results The male to female ratio was 9:1 (27 male: 3 female). IH occurred on the right in 16 (53 %), on the left in 3 (10 %) and bilaterally in 11 (37 %) patients. Twelve out of 19 infants with monolateral hernia underwent also closure of contralateral PPV. The mean corrected gestational age at surgery was 49.1 weeks (range 43.2–61 weeks) with a mean body weight at operation of 3,800 kg (range 1,900–5,000 kg). Three male infants presented with
Discussion IH repair is one of the most common operation in children and it is performed in 1–4 % of all children [12]. In the last decade, despite laparoscopic IH repair has become popular in children, there are few reports in newborns. Turial et al. [4] and Esposito et al. [5] have recently published their experiences with encouraging results. The use of laparoscopic IH repair in neonates is a technically demanding procedure because intra-corporeal suturing requires to be done in a very limited space. However, open herniotomy in newborns is also considered a technically demanding surgery [13] with an increased overall rate of complications (recurrence, testicular hypotrophy/atrophy, high testis) compared to older children. Moreover, serious intra-operative complications such as bladder rupture or injury, which can occur in open surgery, due to excessive mobilization of the sac [14], are unlikely with the laparoscopic approach which allows a better visualization of the anatomic structures. Furthermore, during laparoscopic repair, the risk of complications associated with dissection is minimized. This advantage is important, especially in neonates, in whom the vas deferens and the vessels are very small and the hernia sac very friable. In our study, we had no intra- or post-operative complications such as testicular hypotrophy/atrophy. Another clear advantage of laparoscopic repair is to treat bilateral IH in the same operation or close a contralateral PPV in order to prevent future metachronous IH. This is particularly important for newborn and preterm babies, in whom the risk of metachronous IH is higher. In our series, not only 11/30 patients had a pre-operative bilateral IH but also most infants (63 %) with monolateral IH required bilateral closure of PPV. In total, the majority (77 %) of our infants with IH required bilateral herniorraphy. This approach has resulted in the absence of metachronous IH at follow-up. Choi et al. [11]
123
Hernia
reported a higher recurrence rate in older children ([12 months) when compared to infants (\12 months). The recurrence rate in infants who underwent laparoscopy seems even lower than many series of open IH repair in babies [11, 13, 15]. Our success could be due to the particular attention paid to the medial aspect of the internal inguinal ring. In fact, it is important to put the most medial stitches as close as possible to the epigastric vessels and vas deferens. At the beginning of our experience in older children, in fact, we approached the internal ring by sectioning the peritoneum after having placed around it a pullstring absorbable suture. In our hands, this technique was associated with a 4 % recurrence rate but, since we started to leave intact the peritoneum and use non-absorbable sutures, the rate of recurrence dramatically dropped. By the way, in our opinion, the key of the success is the use of non-absorbable suture, independently from the type of the technique (resection or not of the peritoneum) used, as long as the medial side of PPV is properly closed. Other advantages of laparoscopy are superior cosmesis and low wound infection rate (2.3 % in open repair by Nagraj et al. [13] ). This last finding may be due to the higher location of wound incision in the abdomen in infants treated laparoscopically when compared to those who underwent inguinal incision. In fact, especially in this age group, inguinal scars are more subject to urine and fecal contamination. Another common question among pediatric surgeons concerns timing for elective IH repair in neonates. All IH have to be repaired to avoid the risk of incarceration of bowel and gonadal infarction and atrophy [16], but these risks must be balanced against the risk of potential operative and anesthetic complications. Lautz et al. [17] determined that the overall rate of IH incarceration was 16 % and that the risk was higher in infants in whom surgery was delayed beyond 40 weeks’ corrected gestational age as compared with those repaired before. Conversely, other authors [18] reported no episodes of IH incarceration while awaiting repair in preterm who had been discharged from the hospital with known IH and scheduled for a planned elective surgery. Furthermore, Uemura et al. [19] reported comparable IH incarceration rates in preterm infants who underwent repair after 2 weeks from diagnosis when compared to those who underwent more urgent surgery. Other investigators have reported a higher rate of surgical complications in infants operated when they were 43 weeks’ corrected gestational age or younger [20] and a higher incidence of postoperative apnea (49 %) [21] which significantly decreases when operating at 45.3 weeks of corrected gestational age [22]. In accordance with literature, we prefer to repair IH when the neonates are 45 corrected weeks’ gestation or when they are at least 2,100 kg (just before discharge from the NICU). In this series no anesthetic problems occurred and all the neonates
123
were promptly extubated after surgery. Neonates with respiratory problems underwent open IH repair by spinal anesthesia and were not included in this study. Despite laparoscopic IH repair has always been considered a timeconsuming procedure, more reports showed that operative time of laparoscopic IH repair is not only comparable with time of open standard herniotomy [23] but also, especially in neonates and certainly in bilateral IH, it could be shorter when the laparoscopic surgeon has gained enough experience. Considering the higher chances for newborns of developing a contralateral IH [4], laparoscopic repair resolves the problem bilaterally at once, thus obviating the need for a second operation and thus anesthesia, and reducing both economic impact and risk to the patient [24]. After the learning curve period, our mean operative time decreased a lot and now it usually is less than 30 min in all cases.
Conclusion In conclusion, we believe that laparoscopic IH repair in newborns and in ex-preterm infants is a safe, effective and less technically demanding procedure than open herniotomy. The risk of recurrence and complication still exists but it is minimal. Furthermore, it is a useful alternative to open repair when the surgeon has acquired enough experience in laparoscopic surgery. We think that 45 weeks’ corrected gestational age is a safe period for IH repair for both surgeons and anesthesiologists. Conflict of interest V.P. declares no conflict of interest. F.B. declares no conflict of interest.
References 1. Grosfeld JL (1989) Current concepts in inguinal hernia in infants and children. World J Surg 13:506–515 2. Chan IHY, Lau CT, Chung PHY, Chan KL, Lan LCL, Wong KKY, Tam PKH (2013) Laparoscopic inguinal hernia repair in premature neonates: is it safe? Pediatr Surg Int 29:327–330 3. Turial S, Enders J, Krause K, Schier F (2010) Laparoscopic inguinal herniorraphy in premature infants. Eur J Pediatr Surg 20:371–374 4. Turial S, Enders J, Krause K, Schier F (2011) Laparoscopic inguinal herniorraphy in babies weighing 5 kg or less. Surg Endosc 25:72–78 5. Esposito C, Turial S, Escolino M, Giurin I, Alicchio F, Enders J, Krause K, Settimi A, Schier F (2012) Laparoscopic inguinal hernia repair in premature babies weighing 3 kg or less. Pediatr Surg Int 28:989–992 6. Shalaby R, Ibrahem R, Shahin M, Yehya A, Abdalrazek M, Alsayaad I, Shouker MA (2012) Laparoscopic hernia repair versus open herniotomy in children: a controlled randomized study. Minim Invasive Surg 2012:484135 7. Parelkar SV, Oak S, Gupta R, Sanghvi B, Shimoga PH, Kaltari D, Prakash A, Shekhar R, Gupta A, Bachani M (2010) Laparoscopic
Hernia
8.
9.
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13.
14.
15.
inguinal hernia repair in the pediatric age group-experience with 437 children. J Pediatr Surg 45:789–792 Perlstein J, Du Bois JJ (2000) The role of laparoscoy in the management of suspected recurrent paediatric hernias. J Pediatr Surg 35:1205–1208 Schier F, Montoupet P, Esposito C (2002) Laparoscopic inguinal herniorraphy in children: a three-center experience with 933 repairs. J Pediatr Surg 37:323–327 Ron O, Eaton S, Pierro A (2007) Systematic review of the risk of developing a metachronous contralateral inguinal hernia in children. Br J Surg 94:804–811 Choi W, Hall NJ, Garriboli M, Ron O, Curry JI, Cross K, Drake DP, Kiely EM, Eaton S, De Coppi P, Pierro A (2012) Outcomes following laparoscopic inguinal hernia repair in infants compared with older children. Pediatr Surg Int 28:1165–1169 Geisler DP, Jegathesan S, Parmley MC, McGee JM, Nolen MG, Broughan TA (2001) Laparoscopic exploration for the clinically undetected hernia in infancy and childhood. Am J Surg 182: 693–696 Nagraj S, Sinha S, Grant H, Lakhoo K, Hitchcock R, Johnson P (2006) The incidence of complications following primary inguinal herniotomy in babies weighing 5 kg or less. Pediatr Surg Int 22:500–502 Miyano G, Yamataka A, Okada Y, Shimotakahara A, Kaneko K, Lane GJ, Yamashiro Y, Miyano T (2004) Sigmoidocolocystoplasty for augmentation of iatrogenic small capacity bladder caused by direct injury to the bladder durind inguinal hernia repair: long term follow up. Pediatr Surg Int 20:61–64 Phelps S, Agrawal M (1997) Morbidity after neonatal inguinal herniotomy. J Pediatr Surg 32:445–447
16. Rescorla FJ, Grosfeld JL (1984) Inguinal hernia repair in the perinatal period and early infancy: clinical considerations. J Pediatr Surg 19:832–837 17. Lautz TB, Raval MV, Reynolds M (2011) Does timing matter? a national perspective on the risk of incarceration in premature neonates with inguinal hernia. J Pediatr 158:573–577 18. Lee SL, Gleason JM, Sydorak RM (2011) A critical review of premature infants with inguinal hernias: optimal timing of repair, incarceration risk and postoperative apnea. J Pediatr Surg 46:217–220 19. Uemura S, Woodward AA, Amerena R, Drew J (1999) Early repair of inguinal hernia in premature babies. Pediatr Surg Int 15:36–39 20. Baird R, Gholoum S, Laberge JM, Puligandla P (2011) Prematurity, not age at operation or incarceration, impacts complication rates of inguinal hernia repair. J Pediatr Surg 46:908–911 21. Malvija S, Swartz J, Lerman J (1993) Are all preterm infants younger than 60 weeks postconceptual age at risk for postanesthetic apnea? Anesthesiology 78:1076–1081 22. Cote` CJ, Zaslavsky A, Downes JJ, Kurth CD, Welborn LG, Warner LO, Malviya SV (1995) Postoperative apnea in former preterm infants after inguinal herniorraphy. a combined analysis. Anesthesiology 82:809–822 23. Yang C, Zhang H, Pu J, Mei H (2011) Laparoscopic vs open herniorraphy in the management of pediatric inguinal hernia: a systemic review and meta-analysis. J Pediatr Surg 46:1824–1834 24. Montoupet P, Esposito C (1999) Laparoscopic treatment of congenital inguinal hernia in children. J Pediatr Surg 43:420–423
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ORIGINAL ARTICLE
Neonatal laparoscopic inguinal hernia repair: a 3-year experience V. Pastore • F. Bartoli
Received: 24 November 2013 / Accepted: 23 May 2014 Ó Springer-Verlag France 2014
Abstract Purpose To retrospectively analyze the feasibility, safety and complication rate of laparoscopic inguinal herniorraphy in babies weighing 5 kg or less. Methods Thirty infants weighing 5 kg or less underwent laparoscopic inguinal hernia repair during a 3-year period. Twenty-eight infants were born preterm and the mean body weight at surgery was 3,800 kg. Internal inguinal ring was closed with a non-absorbable purse-string suture. Contralateral processus vaginalis was closed if patent. Feeding was started on the same day and the patient discharged the following day. Follow-up consisted of physical examination at 1 week, 6 and 12 months postoperatively. Results Of the 30 patients (27 males, 3 females), 11 had bilateral and 19 monolateral hernia (16 right, 3 left). At laparoscopy, 23 infants needed to have bilateral herniorraphies. The mean corrected gestational age at surgery was 49.1 weeks. The mean operative time for repair was 30 min for unilateral and 41 min for bilateral hernia. There were not intra- or post-operative complications as well as conversions or recurrences. Conclusions Laparoscopic inguinal hernia repair in newborns and in ex-preterm infants is a safe and effective procedure to perform and, perhaps, even less technically demanding than open herniotomy.
V. Pastore (&) F. Bartoli Pediatric Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto 1, 71122 Foggia, Italy e-mail: [email protected]
Keywords Inguinal hernia Laparoscopy Newborn Preterm-infant
Introduction Inguinal hernia (IH) is a common condition requiring surgical repair in the pediatric age group. Its incidence is 3–5 % in term and 13 % in preterm infants (\36 weeks of gestational age) [1]. Open herniotomy is the standard procedure against which all other alternatives have to be compared. During the last decade, laparoscopic IH repair has become a routine procedure in older children but its use in neonates and premature babies is still limited [2– 5]. Reported advantages of laparoscopic hernia repair include excellent visual exposure, minimal dissection of vas deferens and spermatic vessels, fewer complications, comparable recurrence rates, and improved cosmetic results compared with the traditional open approach [6]. In addition, laparoscopic hernia approach allows diagnosis and repair of contralateral patent processus vaginalis (PPV), uncommon types of hernias (es. femoral, direct, combined hernia) and recurrent or complicated hernia [7, 8]. During the first year of life, the probability of finding a PPV on the contralateral side may be up to 50 % of cases [9] and the incidence of metachronous hernia ranges from 1 to 38 % as attested in different studies [10]. Recently, few authors have reported successful treatment of these infants through laparoscopy. Furthermore, the timing of IH repair in infants—early or delayed—is still a matter of discussion. The purpose of this study has been to retrospectively analyze the feasibility, safety, and complication rate of laparoscopic inguinal herniorraphy in babies weighing 5 kg or less.
123
Hernia
Operative technique
placement of the stitch on the lateral and inferior border of PPV (Fig. 3). The suture proceeds on inferior margin and is completed by stitching the peritoneum on lateral and superior margin (Figs. 4, 5). This procedure avoids obstruction of vas and spermatic vessels because they lie in the retroperitoneal space. The contralateral processus vaginalis was examined for patency and it was closed in the same manner without the need to change the trocar positions. We consider PPV if a 3-mm Kelly forceps can be introduced into the processus vaginalis for a length of at least 1 cm (the length of the opening jaws). The needle was extracted transparietally, in the same way as the insertion and the incisions closed. Feeding was started on the same day of the procedure and the patient discharged on the first post-operative day. Follow-up consisted in clinical
All surgical procedures were performed with the neonate in a supine position under general anesthesia using tracheal intubation. A 5-mm 0° laparoscope was placed through the umbilical port by open Hasson’s technique to minimize the risk for bowel injury. Two further 3 mm working instruments were placed at right and left lower quadrant of the abdomen. Pneumoperitoneum was kept at a pressure of 6–8 mmHg to avoid ventilation problems during surgery. A 4–0 non-absorbable monofilamentous suture was inserted directly through the abdominal wall next to the internal inguinal ring and PPV was closed with a purse-string suture at level of the internal inguinal ring. The purse-string suture is placed on the peritoneum by starting from the level of medial and superior margin of the internal inguinal ring as suggested by several authors [7, 11] (Fig. 1). Then, the peritoneum between vas and spermatic vessels is carefully lifted with the help of grasper (to protect spermatic cord structure) (Fig. 2) for a better and safer
Fig. 2 The peritoneum between vas and spermatic vessels is carefully lifted with the help of grasper
Fig. 1 Open left internal inguinal ring and first stitch on medial and superior margin
Fig. 3 Placement of the stitch on the lateral and inferior border of left PPV
Methods Patients We reviewed the charts of 30 infants with IH weighing \5 kg who underwent laparoscopic repair at our institution over a 3-year period. All the patients were operated by the same senior author. The mean body weight at surgery was 3,800 kg (range 1,900–5,000 kg) and 28 out of 30 patients (93 %) were premature born \36 weeks’ gestation. Laparoscopic IH repair was carried out when the babies were older than 45 corrected weeks’ gestation or when they reached 2,100 kg.
123
Hernia
incarcerated IH, but only one was treated earlier (when its body weight was still 1,900 kg) because of repeated incarceration episodes. The mean operative time for hernia repair was 30 min (range 20–35) for unilateral and 39 min (range 26–51) for bilateral IH. There were no intra- or postoperative complications or need for conversion. No patient suffered apnea episodes after the procedure. All the babies started feeding on the same day of surgery and all were discharged from the hospital the day after. No recurrences or metachronous IH were detected at a mean follow-up of 21 months (range 6–40). Cosmesis was excellent and no wound infection was found. Four boys had undescended testis before surgery (2 bilateral and 2 monolateral) but only 3 of them required subsequent orchiopexy at 10 months of age. Fig. 4 The purse-string suture ends at superior and lateral margin of left ring
Fig. 5 Final view of the closed left internal inguinal ring with nonabsorbable suture
evaluation at 1 week, 6 months and 1 year. For this study’s purpose a phone interview was done about clinical outcome.
Results The male to female ratio was 9:1 (27 male: 3 female). IH occurred on the right in 16 (53 %), on the left in 3 (10 %) and bilaterally in 11 (37 %) patients. Twelve out of 19 infants with monolateral hernia underwent also closure of contralateral PPV. The mean corrected gestational age at surgery was 49.1 weeks (range 43.2–61 weeks) with a mean body weight at operation of 3,800 kg (range 1,900–5,000 kg). Three male infants presented with
Discussion IH repair is one of the most common operation in children and it is performed in 1–4 % of all children [12]. In the last decade, despite laparoscopic IH repair has become popular in children, there are few reports in newborns. Turial et al. [4] and Esposito et al. [5] have recently published their experiences with encouraging results. The use of laparoscopic IH repair in neonates is a technically demanding procedure because intra-corporeal suturing requires to be done in a very limited space. However, open herniotomy in newborns is also considered a technically demanding surgery [13] with an increased overall rate of complications (recurrence, testicular hypotrophy/atrophy, high testis) compared to older children. Moreover, serious intra-operative complications such as bladder rupture or injury, which can occur in open surgery, due to excessive mobilization of the sac [14], are unlikely with the laparoscopic approach which allows a better visualization of the anatomic structures. Furthermore, during laparoscopic repair, the risk of complications associated with dissection is minimized. This advantage is important, especially in neonates, in whom the vas deferens and the vessels are very small and the hernia sac very friable. In our study, we had no intra- or post-operative complications such as testicular hypotrophy/atrophy. Another clear advantage of laparoscopic repair is to treat bilateral IH in the same operation or close a contralateral PPV in order to prevent future metachronous IH. This is particularly important for newborn and preterm babies, in whom the risk of metachronous IH is higher. In our series, not only 11/30 patients had a pre-operative bilateral IH but also most infants (63 %) with monolateral IH required bilateral closure of PPV. In total, the majority (77 %) of our infants with IH required bilateral herniorraphy. This approach has resulted in the absence of metachronous IH at follow-up. Choi et al. [11]
123
Hernia
reported a higher recurrence rate in older children ([12 months) when compared to infants (\12 months). The recurrence rate in infants who underwent laparoscopy seems even lower than many series of open IH repair in babies [11, 13, 15]. Our success could be due to the particular attention paid to the medial aspect of the internal inguinal ring. In fact, it is important to put the most medial stitches as close as possible to the epigastric vessels and vas deferens. At the beginning of our experience in older children, in fact, we approached the internal ring by sectioning the peritoneum after having placed around it a pullstring absorbable suture. In our hands, this technique was associated with a 4 % recurrence rate but, since we started to leave intact the peritoneum and use non-absorbable sutures, the rate of recurrence dramatically dropped. By the way, in our opinion, the key of the success is the use of non-absorbable suture, independently from the type of the technique (resection or not of the peritoneum) used, as long as the medial side of PPV is properly closed. Other advantages of laparoscopy are superior cosmesis and low wound infection rate (2.3 % in open repair by Nagraj et al. [13] ). This last finding may be due to the higher location of wound incision in the abdomen in infants treated laparoscopically when compared to those who underwent inguinal incision. In fact, especially in this age group, inguinal scars are more subject to urine and fecal contamination. Another common question among pediatric surgeons concerns timing for elective IH repair in neonates. All IH have to be repaired to avoid the risk of incarceration of bowel and gonadal infarction and atrophy [16], but these risks must be balanced against the risk of potential operative and anesthetic complications. Lautz et al. [17] determined that the overall rate of IH incarceration was 16 % and that the risk was higher in infants in whom surgery was delayed beyond 40 weeks’ corrected gestational age as compared with those repaired before. Conversely, other authors [18] reported no episodes of IH incarceration while awaiting repair in preterm who had been discharged from the hospital with known IH and scheduled for a planned elective surgery. Furthermore, Uemura et al. [19] reported comparable IH incarceration rates in preterm infants who underwent repair after 2 weeks from diagnosis when compared to those who underwent more urgent surgery. Other investigators have reported a higher rate of surgical complications in infants operated when they were 43 weeks’ corrected gestational age or younger [20] and a higher incidence of postoperative apnea (49 %) [21] which significantly decreases when operating at 45.3 weeks of corrected gestational age [22]. In accordance with literature, we prefer to repair IH when the neonates are 45 corrected weeks’ gestation or when they are at least 2,100 kg (just before discharge from the NICU). In this series no anesthetic problems occurred and all the neonates
123
were promptly extubated after surgery. Neonates with respiratory problems underwent open IH repair by spinal anesthesia and were not included in this study. Despite laparoscopic IH repair has always been considered a timeconsuming procedure, more reports showed that operative time of laparoscopic IH repair is not only comparable with time of open standard herniotomy [23] but also, especially in neonates and certainly in bilateral IH, it could be shorter when the laparoscopic surgeon has gained enough experience. Considering the higher chances for newborns of developing a contralateral IH [4], laparoscopic repair resolves the problem bilaterally at once, thus obviating the need for a second operation and thus anesthesia, and reducing both economic impact and risk to the patient [24]. After the learning curve period, our mean operative time decreased a lot and now it usually is less than 30 min in all cases.
Conclusion In conclusion, we believe that laparoscopic IH repair in newborns and in ex-preterm infants is a safe, effective and less technically demanding procedure than open herniotomy. The risk of recurrence and complication still exists but it is minimal. Furthermore, it is a useful alternative to open repair when the surgeon has acquired enough experience in laparoscopic surgery. We think that 45 weeks’ corrected gestational age is a safe period for IH repair for both surgeons and anesthesiologists. Conflict of interest V.P. declares no conflict of interest. F.B. declares no conflict of interest.
References 1. Grosfeld JL (1989) Current concepts in inguinal hernia in infants and children. World J Surg 13:506–515 2. Chan IHY, Lau CT, Chung PHY, Chan KL, Lan LCL, Wong KKY, Tam PKH (2013) Laparoscopic inguinal hernia repair in premature neonates: is it safe? Pediatr Surg Int 29:327–330 3. Turial S, Enders J, Krause K, Schier F (2010) Laparoscopic inguinal herniorraphy in premature infants. Eur J Pediatr Surg 20:371–374 4. Turial S, Enders J, Krause K, Schier F (2011) Laparoscopic inguinal herniorraphy in babies weighing 5 kg or less. Surg Endosc 25:72–78 5. Esposito C, Turial S, Escolino M, Giurin I, Alicchio F, Enders J, Krause K, Settimi A, Schier F (2012) Laparoscopic inguinal hernia repair in premature babies weighing 3 kg or less. Pediatr Surg Int 28:989–992 6. Shalaby R, Ibrahem R, Shahin M, Yehya A, Abdalrazek M, Alsayaad I, Shouker MA (2012) Laparoscopic hernia repair versus open herniotomy in children: a controlled randomized study. Minim Invasive Surg 2012:484135 7. Parelkar SV, Oak S, Gupta R, Sanghvi B, Shimoga PH, Kaltari D, Prakash A, Shekhar R, Gupta A, Bachani M (2010) Laparoscopic
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8.
9.
10.
11.
12.
13.
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