Laparoscopic Hernia repair in children: Ifs and Buts Vikesh Agrawal MBBS.MS(Gen.Surg.) MCh(Pediatric Surg.) FIAGES Short term Fellow (Pediatric Urology), University of Michigan, USA Short term Fellow (Pediatric MAS), National Hospital of Pediatrics, Hanoi, Vietnam Associate Professor and Head Pediatric Surgery and Pediatric MAS Division, Department of Surgery, Netaji Subhash Chandra Bose Medical College, Jabalpur Deputy Registrar(Academics) Madhya Pradesh University of Health Sciences Jabalpur, India

“I know more than hundred surgeons whom I would cheerfully allow to remove my gallbladder but only one to whom I should like to expose my inguinal canal.” Sir Henage Ogilvie

Prof Felix Schier 11 Landmark publications on pediatric laparoscopic hernia repair Largest published series in the world (1091) Microlaparoscopic repair Eternal teacher of this procedure across the world

Why laparoscopy: Ifs, ifs and ifs! Bilateral: up to 10%?? Cosmesis?? Recovery?? Vasal injury?? Vessel injury?? Recurrence???

Why laparoscopic hernia repair? Major problem with Laparoscopic hernia repair (LHR) is recurrence A main concern is the increased recurrence rate after LHR (up to 6%) Recurrence study: Felix Schier The largest series of recurrences after LHR The intent is to define the problem of recurrence

But! Lesser dissection Contralateral repair Smaller incision Detect other types of hernia A chance to suture??

Anatomy of relevance

Criticisms Not backed by enough statistical evidence! Level I Evidence is lacking Have not defined less experienced surgeon clearly! After how many herniotomies? Open vs Lap hernia: Remains a debate

Incision, Dissection, Excision and Suture Dr Rasik Shah

Incision, Dissection, Excision and Suture I follow same!

Laparoscopic left herniotomy

SILS Hernia

Severity of hernia? : Endoscopy of sac

Contralateral PPV 112 cases of Hernia and hydrocele 82 hernia: 7 (%)

Future: Non suture hernia repair? “Non-suturing techniques are conceivable, have been tried and may replace suturing some day.” Laparoscopic hernia repair with tackers in children

Medial recurrence Inf. Ep. artery Knot

Lateral recurrence Inf. Ep. artery Knot

Facts! Age: <6 years- Thinner tissue Side: Immaterial Gender: Boys- Fear of injury to vas and vessels Experience: No recurrence in last 200 cases, F Schier Medial recurrence are more common: Due to incomplete closure due to fear of injury to Inferior epigastric vessels

Recurrence: Other studies 451 LHR in 314 children of various ages in our institution from September 2002 to September 2006. Technical improvements: (1) decreasing tension on the purse-string knot (2) using an airtight knot (3) stress-testing the airtightness of the knot by increasing intraperitoneal gas pressure 0.4% vs 4.88%, P = .003 Chan KL, Chan HY, Tam PK. Towards a near-zero recurrence rate in laparoscopic inguinal hernia repair for pediatric patients of all ages. J Pediatr Surg. 2007 Dec;42(12):1993-7.

Recurrence: Our experience (n=56) 2009-2012, 1/56, 1.78% Technique Recurrence Extracorporeal 0/22 Intracorporeal 1/16 Non-suturing –Tackers 0/18 Recurrence : 12th case IC We have excluded infants and very large complete hernias

Recurrence; Case 12

Postoperative hydrocele Hydroceles are considered as complications and not as recurrences. How are they treated- With herniotomy? Isn’t a small opening a recurrence? Our experience: 2/56, 3.57% Hydrocele 1: Sclerotherapy with 1% Setrol Hydrocele 2: Sclerotherapy failed, needed herniotomy 3%----------------3.75% (Reviewed study) 1.78%-------------------3.57% (Our study)

Reason for hydrocele Thicker bite at triangle of doom: Lymphatic occlusion Parelkar SV et al. Laparoscopic inguinal hernia repair in the pediatric age group--experience with 437 children. J Pediatr Surg. 2010 Apr;45(4):789-92.

Personal communication: Felix Schier FS: This is unusual. We have only very rarely a hydrocele. It believe it was just bad luck. Lymphatic occlusion I do not believe, because we would see hydroceles far more often if that would be the case. I have no suggestion on how to prevent this.

Recurrence: Our experience (n=112) 2009-2014, 1/112, 0.8% Type Recurrence Hernia 1/82 (1.2%) Hydrocele 0/30 Hernia PPV (4, 4.87%) Hydrocele PPV (3, 10%) 0/4 Hernia 0/3 Hydrocele We have excluded infants and very large complete hernias 1 Recurrence + 1 hydrocele = 2 (1.78%)

Total laparoscopic repair of hydrocele in children

Hydrocele in children Hydrocele types A, Congenital or intermittent hydrocele. B, Scrotal hydrocele. C, Hydrocele of the cord. D, Inguinoscrotal hydrocele. E, Abdominoscrotal hydrocele

The value of laparoscopy in the management of abdominoscrotal hydroceles. Martin K, Emil S, Laberge JM. J Laparoendosc Adv Surg Tech A. 2012 May;22(4):419-21. Abstract INTRODUCTION: Abdominoscrotal hydroceles (ASH) represent a difficult surgical problem in which a large scrotal hydrocele extends through the inguinal canal into the intraabdominal, extraperitoneal space, creating a widened internal ring that may be associated with an inguinal hernia. SUBJECTS AND METHODS: Patients with ASH were repaired using a combined laparoscopic-inguinal approach. Laparoscopic exploration was used to confirm the diagnosis, rule out associated hernia, assess for contralateral pathology, and confirm adequate peritoneal closure at the level of the internal ring, after a standard inguinal approach was used to repair the ASH. RESULTS: Eight patients are described with a median age of 13 months. One patient presented with bilateral ASH, and 5 patients had contralateral pathology, including simple hydrocele (n=3), undescended testicle (n=1), and inguinal hernia (n=2). Three patients were confirmed to have an ipsilateral inguinal hernia associated with their ASH. Postoperative complications included hematoma (n=2) and recurrent hydrocele (n=1). No patient developed ipsilateral or contralateral hernias following ASH repair (median follow-up, 3.2 years). CONCLUSIONS: Although laparoscopy is not essential, we have found it to be a useful adjunct to ensure accurate diagnosis and repair of abdominoscrotal hydroceles in children.

Take home message Acceptable recurrence rate in pediatric hernia repair should be <1% Laparoscopic hernia repair: watertight tension free repair Medial stitch is most important Smaller children are more prone for recurrence Hydroceles are unavoidable??? Open hernia still a valid option!