Current concepts in the management of inguinal hernia and hydrocele in pediatric patients in laparoscopic era

ABSTRACT

The surgical repair of inguinal hernia and hydrocele is one of the most common operations performed in pediatric
surgery practice. This article reviews current concepts in the management of inguinal hernia and hydrocele based on the
recent literature and the authors' experience. We describe the principles of clinical assessment and anesthetic
management of children undergoing repair of inguinal hernia, underlining the differences between an inguinal approach
and minimally invasive surgery (MIS). Other points discussed include the current management of particular aspects of
these pathologies such as bilateral hernias; contralateral patency of the peritoneal processus vaginalis; hernias in
premature infants; direct, femoral, and other rare hernias; and the management of incarcerated or recurrent hernias. In
addition, the authors discuss the role of laparoscopy in the surgical treatment of an inguinal hernia and hydrocele,
emphasizing that the current use of MIS in pediatric patients has completely changed the management of pediatric
inguinal hernias.

Introduction

A surgical intervention for inguinal hernia (IH) and hydrocele is one of the most common operations performed in
children. Inguinal hernia and hydrocele have a common etiology, and the surgical correction of both pathologies is
similar. The advent of minimal access techniques has changed conventional management for the treatment of inguinal
hernia in particular. The incidence of inguinal hernia in children less than 18 years of age ranges from 0.8%–4.4%. About
85% of children with an inguinal hernia present with a unilateral hernia. The incidence of incarceration in untreated
hernias in infants and young children varies between 6% and 18%, but it increases to approximately 30% in infancy.

Bilateral inguinal hernia is significantly more common in younger patients with an incidence of about 50% in children
younger than 1 year. In patients undergoing unilateral hernia repair, there is a 5%–20% chance that a hernia will
develop on the contralateral side requiring a second operation and anesthesia for repair. In the pediatric population,
the traditional inguinal approach is an excellent method for hernia repair. However, there is a potential risk of injury to
the spermatic cord and vas deferens, hematoma, wound infection, iatrogenic cryptorchidism, testicular atrophy, and
recurrence of the hernia.

Laparoscopic inguinal hernia repair (LH) in children was introduced as an alternative to conventional open hernia repair
(OH). It was first described by Montupet in 1993.Many technical variations have been described for LH repair, and can
be categorized as either intracorporeal or extracorporeal/percutaneous. Montupet initially described the technique of
intracorporeal repair, consisting of a purse-string suture in the periorificial peritoneum at the level of the internal ring.
Schier introduced his technique, consisting of an “N”-shaped suture on the periorificial peritoneum. Becmeur et al.
described laparoscopic division and resection of the hernia sac at the level of the internal ring, with subsequent closure
of the peritoneal edges. The extracorporeal techniques all involve the placement of a suture circumferentially around
the internal ring and tying the knot using percutaneous techniques.

Many variations of this approach have been described. Recently, Ostlie and Ponsky reviewed the literature, and stated
that there was insufficient evidence to support one approach over another.

However, the addition of the peritoneal incision intentionally created at the level of the internal inguinal ring, as
reported by Esposito, seems to result in a more durable repair.

The proposed advantages of the laparoscopic technique include visualization of contralateral defects, identification of
less common (direct and femoral) hernias, diminished postoperative pain, improved cosmesis, more rapid return to
normal function, and a lower rate of complications (particularly in infants and complex cases). Potential disadvantages
include possible increase in length of operative time and costs, learning curves, and the need of orotracheal intubation
for anesthesia. The indications for, and contraindications to LH are controversial and the superiority of LH versus OH
continues to be debated.This article aims to evaluate current concepts in the management of inguinal hernia and
hydrocele in an era of minimally invasive surgery.
Diagnosis

The diagnosis of inguinal hernia is clinical. In general, patients with hernia are adequately assessed by history and
physical examination. Their history often reveals the sudden, intermittent appearance of a bulge in the inguinal region
or in the scrotum during diaper change or after bathing. Bulging is also usually seen during crying or with defecation. In
cases of incarcerated hernia, an intestinal obstruction may be present, with vomiting and an abdominal distention. If the
hernia is incarcerated at the time of examination, a mass is usually palpated in the inguinal region (Figure 1). In girls, a
small mobile mass often appears in the groin or labia, which usually represents an ovary. The differential diagnosis of
hernia from a hydrocele is important. In case of hydrocele, there is a painless swelling within the scrotum. It is larger in
the evening than in the morning. Clinical examination reveals a fluctuant painless swelling, which may or may not be
reducible. Transillumination reveals a fluid-filled scrotum that may be bilateral, particularly in infants (Figure 2).

Anesthesia

The majority of infants and children undergoing surgical treatment of hydrocele and hernia require pre-anesthetic
medication and general anesthesia. Separation anxiety can be quite significant, and many factors (genetic, personality,
previous experience, and parenteral anxiety) may influence its severity. Pre-anesthetic tranquilizing medications include
the benzodiazepines and other agents. Oral midazolam is a common pre-anesthetic medication, with dose ranges of
0.25–1.0 mg/kg. Upon arrival to the operating room pulse oximetry, heart rate, and non-invasive arterial blood pressure
are monitored. Anesthesia is induced with sevoflurane 8% in oxygen 6 L/min via face mask. Sevoflurane is currently one
of the volatile agents of choice in pediatric anesthesia for inhalation induction. It is suitable because it has a pleasant
smell, does not irritate the airways and its blood-gas partition coefficient is slightly greater than that of desflurane or
nitrous oxide. Vascular access is obtained (22 or 24-gauge IV) after loss of the eyelash reflex, and opioid is given to
maintain a suitable depth of anesthesia.

Airway management using a laryngeal mask or endotracheal tube are both acceptable alternatives. The relative ease of
insertion and lower rate of airway complications compared to endotracheal intubation makes laryngeal mask use a
logical choice, but an endotracheal tube is the safest strategy for the patient with a full stomach, an irreducible inguinal
hernia, and for laparoscopic surgery.

Anesthetics produce dose-dependent and drug-specific changes in respiratory mechanics and in the central control of
the respiratory center. Inhaled anesthetics decrease muscle tone within the airways, chest wall and diaphragm, in
addition to inhibiting central respiratory drive and responsiveness to ventilatory stimulants such as carbon dioxide.
Intravenous anesthetics may also alter respiratory function, while opioids produce a dose- dependent depression of
medullary respiratory centers, also resulting in decreased responsiveness to partial pressure of carbon dioxide (PaCO2).
For these reasons, regional anesthesia is often used in combination with general anesthesia for pediatric surgery and
has been shown to reduce general anesthetic requirements, opioid use, postoperative nausea and vomiting and pain.

Pain is a major concern in patient recovery. By providing optimal pain management, providers can improve patient and
parent satisfaction, mobility, compliance, hemodynamic alterations from stress responses, and potentially even wound
healing. Regional anesthesia is often used to supplement general anesthesia and provide postoperative analgesia. The
most common forms used are regional nerve block or caudal anesthesia performed after the induction of general
anesthesia. Local anesthetic for regional nerve block after herniorrhaphy is introduced at a puncture site 1- cm medial
to the anterior superior iliac spine. Because the nerves most commonly run below the external oblique, the needle is
advanced until a “click” is felt as the needle passes through the external oblique and the local anesthetic is injected.
Caudal block is performed by injecting local anesthetic into the epidural space via the sacral hiatus. Standard dosing
provides neuraxial blockade of sensory input at and below the T10/umbilical dermatome.

Finally, the intranasal use of clonidine is interesting. Clonidine acts as an agonist at alpha-2 adrenoceptors. The locus
ceruleus (LC) is the site of action for the sedative effect of clonidine. The LC contains a high density of alpha-2
adrenoceptors. Following binding of clonidine to alpha-2 adrenoceptors, hyperpolarization of noradrenergic signaling to
the ventrolateral preoptic area (VLPO) occurs, producing sedation. The drug is rapidly absorbed by the nasal route, and
peak plasma levels are reached within 10 min. No sign of irritation or edema in the nasal cavity has been observed after
a single dose. Intranasal administration of drugs is an easy and minimally invasive alternative route of administration; a
relatively large surface area is available for drug absorption and a thin, very vascularized epithelium ensures rapid
absorption and onset of therapeutic action by avoiding the first-pass effect.

Surgical training

As a surgical trainee learns how to perform an inguinal hernia repair, the open technique is fairly straightforward—
direct observation in the operating room, first helping an expert surgeon and then operating as the primary surgeon.
Laparoscopic training for inguinal hernia repair is quite different.

According to European Society of Pediatric Endoscopic Surgeons Association (ESPES), a laparoscopic training program
has to be completed before starting laparoscopic operations in human subjects. On the basis of our ESPES program, MIS
training for pediatric surgeons must contain the following educational components: (1) theoretical knowledge; (2)
practice-based learning and improvement in an experimental setting, initially on pelvic trainers and then on live animal
models; (3) training in European centers of reference for MIS; and (4) personal operative experience. At the end of the
training program, ESPES will analyze the candidate's training booklet and provide each applicant with ESPES certification
after an exam. This training program has not been officially adopted in Europe, but there are strong recommendations
to follow it, in order to protect pediatric surgeons from a medico-legal point of view in case of complications following a
laparoscopic procedure.

Indications for surgery

Inguinal hernia

Surgery is indicated for all pediatric patients in whom the diagnosis of inguinal hernia has been made. Most surgeons
operate on premature infants with hernias prior to the infant's discharge from the neonatal intensive care unit. Infants
younger than 6 months are usually booked on a soon-available operating list. Older children with few symptoms can be
booked electively. Surgical treatment is offered for inguinal hernia to prevent the complications of incarceration and
obstruction, potentially resulting in vascular insufficiency of the hernia contents (usually a loop of intestine) as well as
surrounding cord structures. In females, torsion/ischemia of the ovary is also possible.

Hydrocele

Surgical indications for hydrocele are mostly age dependent. Most surgeons advocate observation of hydroceles in
infants younger than 24 months. Others may continue observation for longer, as the majority of PVDs (peritoneo-
vaginal ducts) will close within the first 24–36 months of life.

Timing of surgery

As mentioned, infants younger than 3 months with IH are usually booked on a soon-available operating list and older
children with few symptoms can be operated electively. In case of incarceration, if the hernia is able to be easily
reduced and the child is older than 3 months, the procedure is usually carried out electively.

An attempt at reduction should be made in a patient who presents with an incarcerated hernia. Reduction should be
per- formed by an experienced physician, using analgesia and/or sedation. Reduction may spontaneously occur prior to
a manual attempt if the infant's buttocks are elevated slightly to assist in the reduction of hernia contents. The hernia is
palpated distally while the clinician's fingers are placed at the proximal neck of the hernia. Compression of the hernia
can then occur. The pressure is maintained slowly and consistently until the hernia is reduced. Incarcerated hernias that
are reduced have an incidence of reincarceration as high as 15% if definitive repair is delayed more than 5 days. If a
hernia cannot be completely reduced, an operative approach is indicated to reduce the hernia, inspect the integrity of
the contents, and to ligate the hernia sac.

Operative positioning
In open inguinal repair, the surgeon's position is ipsilateral to the pathology. However, with laparoscopic hernia repair
the patient is always in supine position but with a 151–201 Trendelenburg inclination to reduce the intra-abdominal
pressure (IAP) and abdominal contents. The bladder should be emptied before surgery. The video column is positioned
at the foot of the patient, the surgeon at the head of the patient, and the camera operator contralateral to the
pathology (hernia).

Operative approaches to inguinal hernia and hydrocele

Inguinal hernia and hydrocele in children can be treated through either an open or laparoscopic technique.

Open inguinal approach

The open technique of inguinal hernia repair requires an inguinal approach. A 3–4-cm long inguinal incision is made on
the side ipsilateral to the symptomatic inguinal hernia. The procedure involves the separation of the hernia sac from the
surrounding cord structures, including cremasteric muscle, vas deferens, and the testicular vessels or round ligament
(Figure 3). A ligature is applied to the proximal separated sac, and the distal sac is divided. There is no evidence in the
literature favoring absorb- able versus non-absorbable suture. Historically, during the open repair of a unilateral inguinal
hernia, contralateral patency of the processus vaginalis was not assessed. In the 1980s, French pediatric surgeons
described a technique to identify a contralateral processus vaginalis or hernia, consisting of the passage of a 451 or 701
angled telescope through the hernia sac prior to ligation (hernioscopy). This technique requires the creation of pneumo-
peritoneum and use of the full range of laparoscopic equipment; for this reason, it is infrequent (in our experience) in
clinical practice.

The treatment of hydrocele requires the same surgical procedure described for open inguinal herniotomy. In older
children, a scrotal approach may be adopted. In case of communicating hydrocele, an inguinal incision is performed, the
PVD is ligated and sectioned, and an attempt is made to empty the distal fluid, if not already drained. This often requires
an incision distally, down to the scrotal tunica vaginalis, to release any residual fluid.

Laparoscopic technique

The laparoscopic approach can be performed either transperitoneally or through a pre-peritoneal approach (using
special needles) with transperitoneal visualization. The transperitoneal laparoscopic approach uses 3 ports and a 01, 5-
or 10-mm telescope is inserted through the umbilical port, allowing direct visualization of the internal inguinal rings.
Two 3-mm trocars are inserted in triangulation for good ergonomics. In all, 5- or 10-mm optics both result in a nearly
invisible umbilical scar; selection of one over the other depends on the instruments available or surgeon preference.
Most authors prefer 3-mm screw trocars, particularly in infants o10 kg in whom the skin and underlying tissues are very
thin. Smooth trocars can be easily displaced in these children, creating subcutaneous emphysema. Screw trocars are
more stable and enable rapid change of instruments without dislodgement and gas leaks (Figure 4). If the only trocar
available is of the smooth variety, a piece of Nelaton catheter may be placed around the cannula, with suture fixation of
the catheter to the skin to stabilize the trocar (Figure 4). Some surgeons prefer to use instruments without the
assistance of trocars (via stab incisions), but this technique may make instrument change difficult.

The laparoscopic technique affords confirmation of the diagnosis, as well as inspection of the contralateral side for the
presence of a hernia or a contralateral patent peritoneal vaginalis duct (CPVD). For intracorporeal hernia ligation, the
needle has to be introduced into the abdominal cavity trans-parietally and then removed trans-parietally or
transumbilically. Our preferred needle is 3/8 of a circle with a 20–22-mm needle. To perform a unilateral closure, the
length of suture is 13–15 cm; for a bilateral repair, we use 15–20-cm long suture, but this may vary according to the
surgeon's preference. After sectioning the periorificial peritoneum, the internal inguinal ring is then closed, either with
absorbable or permanent suture. A purse string suture as described by Montupet (Figure 5), or an “N”- suture as
described by Schier can be used. These 2 techniques seem to yield similar long-term outcomes in the literature. A
peritoneal flap closure is an alternative technique using this access method.
In the pre-peritoneal (“needlescopic”) approach, a small hook loaded with a suture is passed around the deep ring after
making a very small inguinal skin incision. The passage of the suture is observed via an endoscope via the umbilicus. The
ligature is then brought out extracorporeally and tied, thus closing the hernia orifice.

Currently, the open inguinal approach remains the preferred technique to treat hydrocele. However, with
communicating hydroceles a laparoscopic repair can be considered. The technique is similar to the laparoscopic repair
described above for inguinal hernia; the fluid is aspirated and the PVD is closed with a purse string suture at the level of
internal inguinal ring.

Laparoscopy has several advantages over open surgery in the treatment of inguinal hernia. There is a reduction of skin
infections, particularly in infants in whom the inguinal incision is inside the diaper with a higher risk of infection, while
laparoscopic incisions are outside the diaper area. Perhaps, the primary advantage of laparoscopy is to identify and to
treat a contralateral patency of PVD, present in about 50% of patients, but increased in younger patients.

Laparoscopy also facilitates the identification and treatment of other types of hernia, such as direct, femoral, and
double hernias (“hernia en pantalon”). A key point of the laparoscopic repair of a direct inguinal hernia is to remove the
lipoma (always present in this pathology) and to close the defect using a purse string suture or separated stitches. In the
case of large defect, the lateral bladder ligament can be used to reinforce the closure.

In addition, laparoscopy is considered the gold standard in the management of recurrent hernia after an open repair,
allowing for identification and treatment of the cause of the recurrence. Laparoscopy is also superior to open inguinal
hernia repair in small infants, as well as for the incarcerated hernia. Reduction of the incarcerated bowl via laparoscopy
is easier to accomplish and concomitant evaluation of bowel viability is possible.

Literature analysis

We performed a literature analysis using PubMed, Cochrane, and Medline databases on all studies published during the
last 20 years that described open or laparoscopic operation for inguinal hernia, and the latter was compared to
conventional OH. The following keywords were used: “inguinal hernia,” “herniorrhaphy,” “hernia repair,” “children,”
“laparoscopic versus open herniorrhaphy,” “laparoscopic versus open hernia repair,” “contralateral patency,”
“complications,” “recurrence,” and “hydrocele.” Searches were also performed using the following limits: clinical trials,
randomized controlled trials, multicenter retrospective, prospective studies, and expert opinion. Conference abstracts
were excluded because of the limited data presented in them. Publications with evidence of possible overlap were also
excluded from this article. Although no language restrictions were imposed initially, the search was limited to studies
published in the English language for the full-text review and final analysis. Eligibility criteria included all available
studies focused on LH and/or OH and with quantitative data on outcome parameters. The pediatric population was
defined as younger than 18 years when the patient underwent LH or OH. After relevant titles were identified, the
abstracts of these studies were read to decide if the study was eligible. The full article was retrieved when the
information in the title and/or abstract appeared to meet the objective of our article. The authors independently
assessed selected studies and tabulated data from each article with a predefined data extraction form. Data regarding
the following factors were considered: first author, publication date, study method, participant features, intervention
characteristics, definition of complications, and outcome measures. Outcome parameters for inclusion were patients'
age, sex, affected side, operative time, time to resume full activity, duration of hospital stay, recurrence, metachronous
contralateral hernia, and complications. We identified 203 studies, but 113 of these were excluded from our analysis
using the following criteria: studies in which the outcomes of interest were not reported for 1 of the 2 techniques, or it
was impossible to calculate these from the published results; studies that were not focused on a pediatric population;
and studies reporting modifications of the standard laparoscopic techniques. The chisquared or Fisher's exact test was
used to evaluate the significance of differences between the 2 groups, LH and OH.

Results

Operative time
Of the 90 studies, 38 included in this article reported operative time. The operative time showed very wide variations,
depending on the technique and surgical team experience. The average operative time for the repair of unilateral
inguinal hernia was 30.1 min via the open approach and 23.7 min via laparoscopy, with no significant difference
between the 2 techniques (P 1⁄4 .33). Bilateral hernia repair was significantly longer for the open technique (46.1 min)
compared to laparoscopy (30.9 min) (P 1⁄4 .01). A conversion rate was reported in 10 studies and ranged between 0%
and 1.7%, but in the majority of these studies there were no conversions at all. There is no data in the literature
comparing operative time of hydrocele repair using open versus laparoscopic approaches (Table 1).

Postoperative recurrence and other complications

Reported complications include recurrence, hydrocele, wound infection, iatrogenic cryptorchidism, testicular atrophy,
and injury to the spermatic cord elements. Recurrence rate for OH ranged from 0% to 6%, and LH recurrences ranged
from 0% to 5.5%. Looking at the averages, there was no significant difference regarding reported recurrence rates
between the 2 techniques (P 1⁄4 .66). Analyzing the results for infants only, the recurrence and wound infection rates
seem to be higher after OH compared to LH.

Other complications, such as wound infection, hydrocele, iatrogenic cryptorchidism, and testicular atrophy, were
significantly higher for OH (2.7%) compared to LH (0.9%) (P 1⁄4 .001). In particular, some articles reported that the
incidence of complications such as cryptorchidism and testicular atrophy was always higher after OH than after LH (P
1⁄4 .001).

Rare hernias

Many uncommon hernias were identified in the LH studies, with an incidence ranging from 0.3% to 7.2%. The most
common hernia in this category was a direct hernia (81.5%), followed by femoral hernia (10%), hernia “en pantalon”
(4.3%), and a combination of indirect hernia with femoral hernia (1.4%), indirect hernia with direct and femoral hernia
(1.4%), and Amyand's/Littre's hernia (1.4%) (Table 2). No rare hernias were reported in the literature for OH patients.

Contralateral pathology

Overall, 27 studies reported the coexistence of a unilateral inguinal hernia, with a contralateral patent peritoneal
vaginal duct (CPVD), for an incidence of contralateral patency between 19.9% and 66%. It is interesting to note that the
highest occurrence of CPVD was reported in the smaller infants (Table 2).

Discussion

In the last 2 decades, the advent of minimally invasive surgery has completely changed the management of pediatric
inguinal hernias. Analysis of the international literature demonstrates ongoing discussion about the best management
of an inguinal hernia in children. An interesting finding is that most studies published in the last 20 years have focused
on the laparoscopic approach. Conversely, the literature regarding open treatment of inguinal hernia repair is scanty
and the real incidence of complications after inguinal hernia repair is probably underestimated. There are also few
reports in the literature specifically targeting hydrocele repair, although it appears that the classic treatment of
hydrocele using an inguinal approach still represents the standard of care.

Our article examined the efficacy and safety of the laparoscopic approach compared with the inguinal approach in the
management of inguinal hernia in children. The results of this article in regard to operative time suggested that there
was no significant difference between the 2 approaches for unilateral inguinal hernias (P 1⁄4 .33). However, in patients
with a bilateral hernia, there was a significant reduction in the operative time for LH compared with OH (P 1⁄4 .01). The
operative time did show wide variation, depending on the technique and experience of the surgical team. No significant
differences were observed for recurrence rates between the 2 techniques (P 1⁄4 .66); whereas the rates of other
complications such as wound infection, hydrocele, iatro- genic cryptorchidism, and testicular atrophy were significantly
higher for OH compared to LH (P 1⁄4 .001). In addition, recurrence rate and wound infections in infants were always
higher after OH than after LH. In our opinion, the higher wound infection rate following OH may be due to the fact that
laparoscopic incisions are located higher on the abdominal wall than inguinal incisions, which are inside the diaper area;
for this reason, they are subject to urine or fecal contamination, which may lead to a higher infection rate. In fact,
studies on LH reported fewer wound infections compared with infants of similar age operated through the inguinal
approach (0% for Esposito et al. versus 2.3% for Nagraj et al.).

Complications after OH (vas deferens injuries, iatrogenic cryptorchidism, and testicular atrophy) have been rarely
reported in the last 15–20 years. For this reason, we had to analyze older published series to obtain adequate data for
comparison purposes. We found 5 studies that reported an incidence of postoperative cryptorchidism and testicular
atrophy that was higher after OH than LH (P 1⁄4 .001). Accurate comparisons between the 2 approaches for these
complications suffer from the use of historical controls. There also was a shorter follow-up in the LH series compared to
the OH studies.

The advantages of LH are believed to include better visualization of vital cord structures, which makes dissection of
these structures safer. The dissection field of LH is limited to the peritoneal layer, with the vas deferens and cord left
untouched. Therefore, injury to the vas is not thought to occur very often. This article also reinforces the usefulness of
the laparoscopic approach for the diagnosis of contralateral patency, which may avoid the need for a second surgery
and anesthesic in patients with a metachronous contralateral hernia. It is our feeling that repair of a CPVD should be
offered to all families, since most desire to have the CPVD repaired at the same operative setting when this option is
offered.

A meta-analysis by Miltenburg et al. showed that laparoscopy has a sensitivity of 99.4% and a specificity of 99.5%
(regardless of patient age, sex, or side of presentation) in detection of CPVD and other various forms of hernia. In
particular, laparoscopy provides a clearer view to identify uncommon hernias such as a direct, femoral, or hernia “en
pantalon,” allowing the appropriate operative technique. Zendejas et al. found that the factor most significantly
associated with an increased risk of recurrence was a direct hernia; the most common cause of recurrent inguinal OH is
a direct hernia not recognized at the time of initial repair. Laparoscopy should eliminate this issue. As reported by
Esposito et al. and Lima et al., it is extremely easy to identify a direct hernia during laparoscopy. In laparoscopic direct
inguinal hernia repair, it is important to identify and resect the hernia lipoma (always present); then the surgeon closes
the hernia defect, with the aid of the bladder lateral ligament to reinforce the repair. Another advantage of laparoscopy
may be in the management of incarcerated hernias, especially in infants.

From a technical point of view, the laparoscopic approach is easier but at the same time technically more demanding for
the surgeon, since he or she has to be able to work in a very small space because of the bowel distension. Therefore, it
is often useful to perform 1 or 2 enemas the day before operation and to use simethicone to empty the intestinal loops
of gas, both of which allow the creation of a larger working space in the abdominal cavity. In small infants, true
triangulation between the optical port and the working instruments is difficult because the 2 operative cannulas are
located higher than their usual position; we prefer to position the ports at the same level as the optical cannula to
create more distance between the ports and the internal inguinal ring. By adding these technical refinements, LH has
become an easy approach in difficult repairs such as the neonatal inguinal hernia. Recent literature suggests that neo-
natal inguinal LH is easier and associated with fewer complications than open inguinal hernia repair. In 2 studies, similar
time to full feeds and length of hospital stay were reported in the LH and OH groups. A meta-analysis by Yang et al.
found that LH was superior to OH in the repair of bilateral pathology with a lower rate of metachronous contralateral
hernia and a similar operative time for unilateral hernias, and similar length of hospital stay, recurrence, and
complication rates. They also found a trend toward higher recurrence rate for laparoscopic repair. A potential
disadvantage of LH that is not able to be addressed in this article is the fact that a transabdominal operation is
performed with LH when compared with the extraperitoneal approach with the inguinal crease technique. A second
disadvantage may be that the laparoscopic incisions, although small, are visible above the underwear/ bathing suit line
when compared with the inguinal crease incisions. Prospective randomized trials have not been performed on the
cosmetic aspects of either approach.

An open inguinal approach still seems the preferred way to treat patients with hydrocele. One role for laparoscopy in
the treatment of hydrocele might be in a child with a unilateral inguinal hernia and a contralateral hydrocele. In
conclusion, while the inguinal approach remains the technique of choice to treat hydrocele, in case of inguinal hernia
laparoscopy seems to be a very good alternative to open surgery.
Summary

Analyzing the international literature, LH appears to require shorter operative times for bilateral hernia repair than the
open inguinal crease approach. Recurrence rates appear similar, but the follow-up is shorter in the LH studies. Wound
infection appears more likely after OH, but the incidence is low. Time to resume normal activity is similar with both
approaches. Further prospective investigations, including long-term follow-up, will be needed to accurately identify the
optimal approach for inguinal hernia repair in infants and children.

In conclusion, definitive evidence in the literature about which technique (laparoscopy or inguinal approach) is
preferable to repair an inguinal hernia is still lacking. A reasonable approach is to recognize the importance of the
parental role in the decision process, and to offer to the patient/family both techniques and the advantages and
disadvantages of each.