1. Laparoscopic Hernia repair in children: Ifs and Buts Vikesh Agrawal MBBS.MS(Gen.Surg.) MCh(Pediatric Surg.) Short term Fellow (Pediatric Urology), University of Michigan, USA Invited Adjunct Clinical Faculty (Ped. Urology), UMICH, USA Visiting Pediatric Urologist, Chirayu Medical College, Bhopal Associate Professor, Pediatric Surgery and Pediatric MAS Division, Department of Surgery, Netaji Subhash Chandra Bose Medical College and Hospitals, Madhya Pradesh University of Health Sciences Jabalpur, India

2. “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

3. 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

4. Anatomy of relevance

5. Introduction Major problem with Laparoscopic hernia repair (LHR) is recurrence A main concern is the increased recurrence rate after LHR (up to 6%) The largest series of recurrences after LHR This study analyses the picture in a series of 32 recurrences The intent is to define the problem of recurrence

6. Medial recurrence Knot Inf. Ep. artery

7. Lateral recurrence Knot Inf. Ep. artery

8. 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

9. 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

10. 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.

11. 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

12. Recurrence: Our experience (n=56) Since 2009, 1/56, 1.78% TechniqueRecurrence Extracorporeal0/22 Intracorporeal1/16 Non-suturing –Tackers0/18 Recurrence : 12 th case IC We have excluded infants and very large complete hernias

13. Recurrence; Case 12

14. Hydroceles 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)

15. 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.

16. 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.

17. Laparoscopic left herniotomy

18. 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

19. Tacker repair: Males

20. Tacker repair: Females!

21. SILS Hernia

22. 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!

23. References Takehara H, Yakabe S, Kameoka K (2006) Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: clinical outcome of 972 repairs done in 3 pediatric surgical institutions. J Pediatr Surg 41:1999–2003 Schier F, Montupet P, Esposito C (2002) Laparoscopic inguinal herniorrhaphy in children: a three-center experience with 933 repairs. J Pediatr Surg 37:395–397. Schier F (2006) Laparoscopic inguinal hernia repair: a prospective personal series of 542 children. J Pediatr Surg 41:1081–1084. Schier F (2007) The laparoscopic spectrum of inguinal hernias and their recurrences. Pediatr Surg Int 23:1209–1213. Becmeur F, Dimitriu C, Lacreuse I, Boeyeldieu L, Moog R, Kauffmann I, Me´fat L (2007) Laparoscopic treatment of congenital inguinal hernias in children (212 patients). Arch Pediatr 14:985–988. Chan KL, Chan HY, Tam PK (2007) Towards a near-zero recurrence rate in laparoscopic inguinal hernia repair for pediatric patients of all ages. J Pediatr Surg 42:1993–1997.

24. Severity of hernia? : Endoscopy of sac