Journal of Pediatric Surgery 54 (2019) 2138–2144

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Long-term follow-up of pediatric open and laparoscopic inguinal

hernia repair☆,☆☆
Albert J. Chong a, Helene B. Fevrier b, Lisa J. Herrinton b,⁎
a
Kaiser Permanente Norther California, Oakland Medical Center, 275 W. MacArthur, Oakland, CA, 94611
b
Kaiser Permanente Northern California, Division of Research, 2000 Broadway, Oakland, CA, 94612

a r t i c l e i n f o a b s t r a c t

Article history: Background: Pediatric laparoscopic inguinal hernia repair is not widely accepted.
Received 18 September 2018 Study design: Children 0–14 years who underwent inguinal hernia repair during 2010–2016 at Kaiser
Received in revised form 9 January 2019 Permanente Northern California were classified into five groups: (1) open unilateral repair without contralateral
Accepted 27 January 2019 exploration; (2) open unilateral repair with contralateral laparoscopic exploration (“open+explore”); (3) open
bilateral repair; (4) laparoscopic unilateral repair; and (5) laparoscopic bilateral repair. Outcomes included
Key words:
ipsilateral reoperation, metachronous contralateral repair, incision time, and complications.
Children
Pediatrics
Results: The study included 1697 children. Follow-up averaged 3.6 years after open (N = 1156) and 2.6 years after
Inguinal hernia repair laparoscopic (N = 541) surgery. Metachronous contralateral repair was performed in 3.8% (26/683) of patients with
Laparoscopic surgery open unilateral surgery without contralateral exploration, 0.7% (2/275) of open+explore patients, and 0.9% (3/336)
Open surgery of laparoscopic unilateral patients (p b 0.01). Ipsilateral repair was performed in 0.8% (10/1156) of open repairs and
Outcomes research 0.3% (2/541) of laparoscopic repairs. Chart review confirmed 5 postoperative infections in 1156 patients with open
surgery (0.43%) and 6 infections in 541 patients with laparoscopic surgery (1.11%) (p = 0.11).
Conclusion: Our study's laparoscopic and open approaches have similar low ipsilateral reoperation rates, incision
times, and complications. The use of laparoscopy to visualize the contralateral side resulted in a significantly
lower rate of metachronous contralateral repair.
Level of evidence: Level III.
© 2019 Elsevier Inc. All rights reserved.

Minimally invasive techniques have been accepted for many surgical
procedures performed in infants and children. Inguinal hernia repair is
one of the most common pediatric procedures, and yet, no laparoscopic
approach to inguinal hernia repair has gained widespread acceptance.
Several reasons account for this, including the need for multiple incisions
for ports, difficulty in the technique, lengthy operative times, higher
costs, lack of large studies with long-term follow-up, and concern
about possible increased recurrence rate [1–3].
In 2011, a new laparoscopic inguinal hernia repair technique was
introduced to the Permanente Medical Group [4]. The technique uses
a single port and is technically relatively simple. Beginning in 2011,
the surgeon taught the procedure to three other surgeons at his
facility, who thereupon switched from open surgery to the laparo-
scopic approach. In addition, the procedure was adopted by a
surgeon at a second facility. This gave us the opportunity to evaluate
the relative effectiveness and safety of laparoscopic compared with
open surgery for pediatric inguinal hernia repair. We conducted
this study to test the null hypotheses that open and laparoscopic
surgery would have similar risk of ipsilateral reoperation and
metachronous contralateral repair, similar average incision time,
and similar risk of complications.
1. Methods

Kaiser Permanente Northern California is a community-based

Abbreviations: IIR, Internal inguinal ring; ASA, American Society for Anesthesia; HR,
hazard ratio; CI, confidence interval.
☆ Role of Study Sponsor: This research was supported by The Permanente Medical
Group. The sponsor had no role in in the collection, analysis and interpretation of data;
in the writing of the report; or in the decision to submit the article for publication.
☆☆ Declaration of interest: None on behalf of all authors.
⁎ Corresponding author at: Division of Research, 2000 Broadway, Oakland, CA 94612.
Tel.: +1 510 891 3714.
E-mail address: lisa.herrinton@kp.org (L.J. Herrinton).
health care system that owns its hospitals and medical offices. For
most patients, care is capitated (prepaid) and comprehensive. All clini-
cal information is recorded into an electronic health record that can be
accessed for research. Prior to introduction of the laparoscopic tech-
nique, pediatric surgeons performed inguinal hernia repair using the
traditional open approach. Some surgeons who perform open surgery
explore the contralateral side laparoscopically with trocar insertion

https://doi.org/10.1016/j.jpedsurg.2019.01.064
0022-3468/© 2019 Elsevier Inc. All rights reserved.
 A.J. Chong et al. / Journal of Pediatric Surgery 54 (2019) 2138–2144
through the open hernia sac or through the umbilicus, while others did
not explore the contralateral side. More than 99% of hernia repairs are
performed as elective procedures and as same-day hospitalizations.
1.1. Description of the laparoscopic technique
All patients undergo general anesthesia, mostly through a laryngeal
mask airway, but occasionally through endotracheal intubation. A
5-mm expandable trocar (STEP TM, Covidien, Boulder, CO) is placed
at a port at the umbilicus. The peritoneal cavity is insufflated to
pressures of 12 to 15 mmHg and the two internal inguinal rings (IIR)
are inspected. The percutaneous ligation technique uses a single 5 mm
port at the umbilicus and a 1 mm stab incision over the IIR at the in-
volved inguinal region. A 25-gauge needle delivering 0.25% bupivacaine
or normal saline is used to hydrodissect the peritoneum away from
the underlying structures (vas deferens, spermatic vessels). Following
the stab incision, a 17-gauge Tuohy needle is used to encircle the IIR
half-way and thereby enter the peritoneal cavity. A 2-0 polypropylene
suture (Surgipro TM, Covidien, Mansfield, MA) loop is inserted and
the other half of the IIR is encircled using the Tuohy needle. The needle
then enters the peritoneal cavity at the halfway point through the
suture loop. Another polypropylene suture loop is then inserted. By
pulling on the first suture loop, the IIR is encircled completely with
the second suture loop and its ends are then externalized. The suture
loop is used to bring a folded 2-0 polyester suture (TiCron TM, Covidien,
Mansfield, MA) tie around the IIR. The tie is then cut in two, and the two
ties are used to ligate the hernia sac at the level of the IIR. In a minority
of cases of incarcerated structures that cannot be reduced, a 3 mm
stab incision is used to insert a 3 mm grasper to assist with the repair.
The umbilicus port site fascia is closed with an absorbable synthetic
polyester (Polysorb TM, Covidien, Boulder, CO) suture and the skin
edges are approximated with a Biosyn monofilament absorbable
suture (Carlsbad, CA). A surgical adhesive or a steristrip is applied to
the inguinal stab incision. The laparoscopic technique allows clear
visualization of the contralateral IIR. Because of the presumed low
morbidity of a contralateral repair, the laparoscopic surgeons in our
setting repair all hernias found on the contralateral internal inguinal
ring, even asymptomatic hernias or patent processus vaginalis.
All patients underwent the standard open inguinal hernia repair. For
the exploration of the contralateral IIR, a 70-degree laparoscope was
used via the ipsilateral hernia sac.
1.2. Study population
The present study included 17 pediatric surgeons at five facilities
who, over the course of the study period, 2010–2016, performed 5 or
more cases of pediatric inguinal hernia repair using either an open or
laparoscopic technique that was introduced by the study surgeon
(AJC). Eligible patients included Kaiser Permanente Northern California
members aged 0–14 years who received an inguinal hernia repair by
an eligible study surgeon and who did not have a prior inguinal hernia
repair. Inguinal hernia repair was ascertained from the description
of the procedure in the operative note. Patients were not required to
have a look-back period before their first surgery because many were
infants. We excluded cases with missing laterality, with an incision
time N 160 min, with American Society for Anesthesiology Physical
Status Classification IV or greater, or with a concurrent tonsillectomy,
appendectomy, orchiectomy, or orchiopexy. We defined five surgical
cohorts based on information recorded into the operative report:
(1) open unilateral repair without exploration of the contralateral side
(“open unilateral”), (2) open unilateral repair with contralateral laparo-
scopic exploration (“open + explore”), (3) open with bilateral repair
(“open bilateral”), (4) laparoscopic with unilateral repair (“lap unilateral”),
and (5) laparoscopic with bilateral repair (“lap bilateral”).
2139
1.3. Data collection
1.3.1. Outcomes
We defined ipsilateral reoperation separately from metachronous
contralateral hernia repair using diagnostic codes (ICD-9, 550.01,
550.03, 550.11, 550.13, 550.91, 550.93; ICD-10, K40.01, K40.11, K40.21,
K40.31, K40.41, K40.91) with information about laterality. However,
these codes were not adequately specific, and so we performed manual
chart review for every case who had a second inguinal hernia repair to
determine the reason for the second surgery. Because the number of
ipsilateral reoperations and metachronous contralateral operations was
small, we defined “second hernia repair” to include any patient who
had a second, later surgery, whether it was ipsilateral, contralateral, or
both. Incision time (cut to close) was determined from the electronic
medical record.
We captured diagnoses of postoperative complications occurring
within 30 days of surgery, including testicular atrophy (ICD-9/10
codes: 608.3/N50.0); granuloma (701.5/L92.9); wound infection
(998.59/T81.4); and unspecific complication, not elsewhere classified
(998.9/T81.9). To enable confirmation of complications, the study
epidemiologist (LJH) prepared extracts of chart notes that concealed
the surgical approach. These extracts were reviewed and coded by the
study surgeon (AJC). Infection was defined as cellulitis, fever, wound
discharge, or erythema with swelling or tenderness. We also sought to
capture postoperative hemorrhage (998.11/L76.22), wound disruption
(998.32/T81.3), foreign body (998.4/T81.5), and accidental puncture
(349.31/T81.2), but these codes were not assigned to any patient.
1.3.2. Baseline covariates
Whether the surgery was unilateral or bilateral was obtained from
structured data recorded into the operative report. Whether the hernia
involved gangrene or obstruction was obtained from ICD-9 and ICD-10
diagnosis codes recorded into the operating room record (without
gangrene or obstruction 550.9, K40.2, K40.9; hernia repair with
gangrene 550.0, K40.1, K40.4; with obstruction 550.1, K40.0, K40.3). In-
carceration of the hernia and hydrocele each was identified using text
search. The birth weights of infants born at Kaiser Permanente were
obtained from a registry of births. The American Society of
Anesthesiologists (ASA) physical status classification was obtained
from the surgical record. Patient age, sex, and race/ethnicity were
obtained from membership data.
1.4. Statistical analysis
We computed the average length of follow-up for each of the five
exposure groups defined by surgical approach. We cross-tabulated
surgical approach, ipsilateral reoperation, metachronous contralateral
repair, and second surgery with patient characteristics. We performed
time-to-event analysis using Cox proportional hazards analysis to com-
pute the adjusted hazard ratio (HR) and its 95% confidence interval (CI)
for the association of surgical approach with risk of a second surgery.
This method accounts for differences in average length of follow-up
between study groups. For this analysis, follow-up started on the day
of the first surgery and stopped on the date of outcome, disenrollment
from the health plan, or on December 31, 2016, the study end date.
We calculated average incision time, plotted incision time to assess
normality, and estimated the association of surgical approach with the
outcome of average incision time using a mixed effects regression
model (multilevel model). The model included terms for patient-level
factors and random intercepts for individual surgeons and for facilities
to account for clustering of patients within surgeons and surgeons
within facilities. Patient-level factors were retained in the statistical
models if they had clinical significance, acted as confounders, or suffi-
ciently improved the goodness of fit as measured by the Akaike infor-
mation criterion. We estimated the frequency of complications and
estimated their 30-day incidence per 1000, with p-values calculated
2140 A.J. Chong et al. / Journal of Pediatric Surgery 54 (2019) 2138–2144

from Chi-square tests. The Kaiser Foundation Research Institute pro-
vided institutional review board approval for this study.
2. Results
2.1. Study population
The number of patients potentially eligible for the study was 2093, of
which 56 (3%) had missing laterality, 15 (b1%) an incision time N 160 min,
4 ASA physical status classification of IV or greater, 5 concurrent tonsillec-
tomy, 9 concurrent appendectomy, and 307 orchiectomy or orchiopexy.
After these exclusions, the number of eligible study subjects was 1697.
The average follow-up from the date of surgery to the end of the
study was 3.6 years (95% CI, 3.4–3.7) after open surgery and 2.6 years
(2.4–2.7) after laparoscopic surgery.
Among the 17 surgeons, one performed only laparoscopy and 12
only open surgery, while 4 switched from open surgery to laparoscopy
during the study period. The average number of surgeries performed
by a surgeon was 100, with range 14–376. Five surgeons performed
more than 100 cases.
Among 1697 children, the initial operation was open unilateral, 683;
open + explore, 275; open bilateral, 198; lap unilateral, 336; and lap
bilateral, 205 (Table 1). Thus, the number of sides was 1354 for open
surgery and 746 for laparoscopic surgery. Laparoscopies were performed
in more recent years. Infants, children with birthweight b2500 g, and
those with higher ASA class were more likely to undergo laparoscopic
surgery and bilateral surgery. Boys and those with hydrocele were
more likely to receive open unilateral surgery.
2.2. Second surgery
During follow-up, 39 children had a second surgery, with most
(72%) occurring after 6 months postop. Four of these children had
their initial unilateral procedure followed by a bilateral procedure and
were counted as both an ipsilateral reoperation and a metachronous
contralateral repair.
Among the 1697 children, 0.71% (N = 12) had an ipsilateral reopera-
tion for a recurrence rate per 1000 person-years of 2.2 (95% CI, 1.2–3.7)
and with no significant difference in frequency across surgical cohorts
(p = 0.50) (Table 2). Counting children with bilateral procedures
twice, once for each side, did not change this result to an important
extent (p = 0.17).
Among 1294 children with an initial unilateral repair, 31 had a
metachronous contralateral repair for a recurrence rate per 1000
person-years of 7.2, 95% CI, 5.0–10.2). The recurrence rate per 1000
person-years was 10.7 (95% CI, 7.1–15.3) for open unilateral; 2.0 (95%
CI, 0.3–6.7) for open+explore, and 3.4 (95% CI, 0.9–9.4) for lap unilat-
eral (p b 0.01). The earliest was on day 48. Counting children with bilat-
eral procedures twice, once for each side, did not change this result
(p b 0.01). We combined open + explore with lap unilateral, because
the contralateral side was explored with each of these approaches. For
this combined group, the recurrence rate per 1,000 person-years of
metachronous contralateral reoperation was 2.7 per 1,000 (95% CI,
1.0-5.9), similar to the rate of 2.2 (95% CI, 1.2-3.7) per 1,000 person-
years after ipsilateral reoperation.
The rate of second surgery (ispilateral or metachronous contralateral)
among children whose initial surgery was open unilateral was 12.7 per
1000 person-years. Compared with open unilateral, the adjusted HR for

Table 1
Characteristics of 1697 children with pediatric inguinal hernia repair, by surgical approach. Kaiser Permanente Northern California, 2010–2016, first procedure only.

Open Unilateral Open +Explorea Open Bilateral Lap Unilateral Lap Bilateral p value

N = 683 N = 275 N = 198 N = 336 N = 205

N % N % N % N % N %

Year of surgery b.0001

2010–11 307 45.0 107 38.9 79 39.9 28 8.3 7 3.4
2012–13 172 25.2 72 26.2 59 29.8 107 31.9 75 36.6
2014–16 204 29.9 96 34.9 60 30.3 201 59.8 123 60.0
Age at first procedure, years b.0001
b1 147 21.5 85 30.9 97 49.0 125 37.2 114 55.6
1–4 245 35.9 84 30.6 58 29.3 79 23.5 48 23.4
5–9 215 31.5 85 30.9 31 15.7 105 31.3 35 17.1
10–14 76 11.1 21 7.6 12 6.1 27 8.0 8 3.9
Sex b.0001
Male 572 83.8 215 78.2 137 69.2 252 75.0 149 72.7
Female 111 16.3 60 21.8 61 30.8 84 25.0 56 27.3
Race/ethnicity b.01
White 312 45.7 123 44.7 84 42.4 151 44.9 80 39.0
African American 61 8.9 34 12.4 24 12.1 43 12.8 24 11.7
Asian-American 124 18.2 41 14.9 34 17.2 53 15.8 46 22.4
Hispanic 92 13.5 35 12.7 27 13.6 44 13.1 33 16.1
Otherb 87 12.7 38 13.8 22 11.1 27 8.0 13 6.3
Missing 7 1.0 4 1.5 7 3.5 18 5.4 9 4.4
Birthweight, g b.0001
b2500 62 9.1 37 13.5 66 33.3 58 17.3 63 30.7
≥2500 352 51.5 141 51.3 93 47.0 175 52.1 101 49.3
Missingc 269 39.4 97 35.3 39 19.7 103 30.7 41 20.0
Complications/concurrent surgeries
Hydrocele 157 23.0 73 26.6 34 17.2 58 17.3 31 15.1 b.01
Incarceration, gangrene, obstruction 40 5.9 10 3.6 12 6.1 20 6.0 14 6.8 b.0001
ASA class b.0001
I 520 76.1 199 72.4 117 59.1 245 72.9 116 56.6
II 151 22.1 69 25.1 72 36.4 78 23.2 71 34.6
III 12 1.8 7 2.6 9 4.6 13 3.9 18 8.8
a
Indicates an open procedure with exploratory laparoscopy of the contralateral side.
b
Includes Native Hawaiian, Pacific Islander, American Indian, and Alaska Native.
c
Not born at Kaiser Permanente.
 A.J. Chong et al. / Journal of Pediatric Surgery 54 (2019) 2138–2144 2141

Table 2
Unadjusted risk of ipsilateral reoperation and metachronous contralateral repair in relation to year of surgery and patient characteristics, 1697 children with pediatric inguinal hernia
repair, Kaiser Permanente Northern California, 2010–2016.a

Ipsilateral Metachronous contralateral repair

No. of surgeries No. of recurrences % p-value No. of unilateral surgeries No. of repairs % p-value

Overall 1697 12b 0.71c 1294 31b 2.40c

Surgery 0.50 0.002
Open Unilateral 683 5 0.73 683 26 3.81
Open+Explore 275 2 0.73 275 2 0.73
Open Bilateral 198 3 1.52 -- -- --
Lap Unilateral 336 2 0.60 336 3 0.89
Lap Bilateral 205 0 0.00 -- -- --
Age at first procedure 0.85 0.40
b1 568 5 0.88 357 7 1.96
1–4 514 4 0.78 408 14 3.43
5–9 471 2 0.42 405 7 1.73
10–14 144 1 0.69 124 3 2.42
Sex 0.25 0.34
Male 1325 11 0.83 1039 27 2.60
Female 372 1 0.27 255 4 1.57
Race /ethnicity 0.58 0.32
White 750 8 1.07 586 18 3.07
African-American 186 0 0.00 138 5 3.62
Asian-American 298 1 0.34 218 5 2.29
Hispanic 231 2 0.87 171 2 1.17
Other 187 1 0.53 152 1 0.66
Birthweight, g 0.71 0.70
≥2500 862 5 0.58 668 18 2.69
b2500 286 3 1.05 157 4 2.55
Missing 549 4 0.73 469 9 1.92
Birth complications
Hydrocele 353 3 0.85 0.72 288 8 2.78 0.63
Incarceration, gangrene, obstruction 96 1 1.04 0.69 70 1 1.43 0.59
ASA status 0.26 0.23
1 1197 6 0.50 964 20 2.07
2 441 5 1.13 298 9 3.02
3 59 1 1.69 32 2 6.25
a
Follow-up averaged 3.6 years after open and 2.6 years after laparoscopic surgery.
b
Of the 12 children with an ipsilateral reoperation, 8 had only a second ipsilateral reoperation and 4 had both a second ipsilateral reoperation and a metachronous contralateral repair.
The later 4 children are counted with both outcomes. Thus, the number of children with a second surgery was 39 (31 + 12 − 4).
c
When children with synchronous bilateral repairs are counted twice, once for each side, the p-values compared open to laparoscopic surgery are 0.17 for ipsilateral recurrence
and b0.01 for metachronous contralateral repair.

the association of open+explore with risk of second surgery was 0.3 (CI,
0.1–0.9, p = 0.03) (Table 3), yielding a number-needed-to-treat (NNT) of
32. The hazard ratios and NNT were nearly identical for open bilateral (HR
0.3, CI 0.1–1.1, p = 0.06, NNT 37) and for lap unilateral (HR 0.3, CI 0.1–1.0,
p = 0.05, NNT 33). No second surgeries were performed among children
who received lap bilateral. Age was not associated with the risk of second
surgery, as shown in the Table 3. The time to second surgery (Fig. 1)
showed no obvious pattern.
Before adjustment, the incision time averaged 36 min for open
unilateral and open + explore, 56 min for open bilateral, 25 min for
lap unilateral, and 31 min for lap bilateral (Table 4). After adjustment
for the patient's baseline characteristics and surgeon, and compared
with open unilateral, the incision time was longer for open+ explore
and open bilateral (p b 0.0001), slightly shorter for lap unilateral
(p = 0.01), and about the same for lap bilateral (p = 0.96). Surgery
was faster in children aged 1–9 years and in girls. It was slower in
those who had ASA classifications II and III.
2.3. Adverse events
Chart review confirmed 5 postoperative infections in 1156 patients
with open surgery (0.43%) and 6 infections in 541 patients with laparo-
scopic surgery (1.11%) (p = 0.11), corresponding to 0.37% among 1354
open sides and 0.80% among 746 laparoscopic sides (p = 0.19). One
patient with open repair underwent reoperation to clean out the infec-
tion, and one laparoscopy patient with a fever had a concurrent respira-
tory infection. In addition, we also noted 3 instances of granuloma
(1 open, 2 laparoscopic, p = 0.70), and 2 of testicular atrophy (2 open,
0 laparoscopic).
3. Discussion
This large observational cohort study of pediatric inguinal hernia
repair assessed outcomes in relation to open and single-incision laparo-
scopic surgery, demonstrating comparably low rates of ipsilateral
reoperation between the two approaches. Many techniques for
performing laparoscopic repair of pediatric inguinal hernias have been
published. Although minimally invasive techniques have been widely
adopted within pediatric surgery, adoption of laparoscopy for inguinal
hernia repair has been lackluster. The literature suggests multiple
concerns: a possible increased recurrence rate; lack of long-term
follow-up in large, well-characterized populations; increased cost;
technical difficulty; the need for multiple ports and incisions; and longer
operative times [1–3]. Our study of 541 children who received laparo-
scopic surgery and were followed for an average 2.6 years after their
surgery addresses many of these concerns. The laparoscopic technique
we use involves a single 5-mm incision at the umbilicus and a 1-mm
stab incision in the inguinal region, thereby avoiding the need for
multiple ports and reducing cost, and possibly reducing incisional pain
and improving cosmesis. The laparoscopic technique was relatively
easily learned and quickly adopted by newer surgeons, including
pediatric urologists, although their patients were not included in the
study because of the large number of concurrent procedures.
Because laparoscopic surgeons could visualize the contralateral
internal inguinal ring and repaired all contralateral hernias found,
2142 A.J. Chong et al. / Journal of Pediatric Surgery 54 (2019) 2138–2144

Table 3
Adjusted hazard ratios for any second surgery,a 1697 children with pediatric inguinal hernia repair, Kaiser Permanente Northern California, 2010–2016.

Variable Number of 1st surgeries Number of 2nd surgeries Hazard ratiob 95% CI P-value
(Denominator) (Numerator)

Surgical approach
Open Unilateral 683 29 1 Ref.
Open+Explore 275 3 0.27 0.1 to 0.9 0.03
Open Bilateral 198 3 0.26 0.1 to 1.1 0.06
Lap Unilateral 336 4 0.34 0.1 to 1.0 0.05
Lap Bilateral 205 0 0 -- -
Age at first procedure, year
b1 568 10 1 Ref.
1–4 514 16 1.34 0.6 to 3.1 0.49
5–9 471 9 1.40 0.4 to 4.5 0.57
10–14 144 4 0.98 0.4 to 2.4 0.97
Sex
Male 1325 34 1 Ref.
Female 372 5 0.54 0.2 to 1.4 0.20
Race/ethnicity
White 750 22 1 Ref.
Nonwhite 947 17 0.58 0.3 to 1.1 0.11
Birthweight, g
≥2500 862 22 1 Ref.
b2500 286 6 0.88 0.4 to 2.2 0.78
Missing 549 11 0.69 0.3 to 1.5 0.35
Complications/concurrent surgeries
Hydrocele vs. no hydrocele 353 8 1.14 0.5 to 2.5 0.75
Incarceration, gangrene, or obstruction vs. none 96 2 1.00 0.2 to 4.2 1.00
ASA class
I 1197 25 1 Ref.
II 441 12 1.51 0.7 to 3.1 0.25
III 59 2 1.86 0.4 to 7.9 0.40
a
Follow-up averaged 3.6 years after open and 2.6 years after laparoscopic surgery. Second surgeries included 12 ipsilateral recurrences and 31 metachronous contralateral repairs among 39 children.
b
The proportional hazards analysis included every variable shown in the table as coded in the table.

Fig. 1. Time to second surgery among 1697 children with pediatric inguinal hernia repair, Kaiser Permanente Northern California, 2010–2016. No child with bilateral laparoscopy had a
second surgery. Four children with both an ipsilateral recurrence and a metachronous contralateral repair are represented in both figures.
 A.J. Chong et al. / Journal of Pediatric Surgery 54 (2019) 2138–2144 2143

Table 4 Among patients who received open surgery without use of laparoscopic
Average adjusted increase or decrease in predicted incision time, minutes, after adjust- exploration, 3.8% required a metachronous contralateral repair, while
ment, in 1697 children with pediatric inguinal hernia repair, Kaiser Permanente Northern
California, 2010–2016, first procedure only.a
0.7% required an ipsilateral reoperation. In contrast, among patients
who received contralateral laparoscopy, the frequency of metachronous
Variable Mean increase or 95% CI P-value contralateral reoperation (0.8%) was nearly identical to the frequency
decrease (−) in
of ipsilateral reoperation (0.7%). The difference in risk of a future contra-
incision time
lateral repair, from 2.4% to about 0.7%, represents a genuine benefit
Surgical approach
without significant morbidity.
Open Unilateral 0.0 Ref.
Open+Explore 7.7 4.9 to 10.6 b.0001 It has also been argued that contralateral groin exploration could
Open Bilateral 22.1 19.4 to 24.8 b.0001 increase the cost, morbidity, and risk of complications above any benefit
Lap Unilateral −4.9 −8.8 to −1.0 0.01 of lowering the risk of future contralateral surgery [14]. Operative time
Lap Bilateral 0.1 −4.0 to 4.3 0.96 translates to the risk associated with exposure to general anesthesia
Age at first procedure, years
[15]. In addition, operative time is a measure of cost. We observed
b1 0.0 Ref.
1–4 −4.2 −6.1 to −2.3 b.0001 that bilateral laparoscopic repair required no more time than open
5–9 −4.3 −6.3 to −2.3 b.0001 unilateral surgery, and it was appreciably faster than open surgery
10–14 −0.7 −3.6 to 2.1 0.61 with contralateral exploratory laparoscopy. This is similar to past
Sex
studies [1].
Male 0.0 Ref.
Female −5.0 −6.8 to −3.1 b.0001 The laparoscopic hernia repair group included children of all ages,
Race/ethnicity including premature infants and teenagers. Despite the large study,
White 0.0 Ref. the number of recurrences and complications was low, and we found
African-American 3.4 1.1 to 5.8 b0.01 no evidence for differences in risk of recurrence (p = 0.85) associated
Asian-American 0.0 −2.0 to 1.9 0.98
with the patient's age. It is our clinical impression that laparoscopic re-
Hispanic −1.1 −3.2 to 1.0 0.30
Other −0.6 −2.9 to 1.7 0.59 pair of incarcerated inguinal hernias is technically easier than when
Birthweight, g using the open approach. Operative times between these approaches
≥2500 0.0 Ref. were similar (p = 0.09).
b2500 0.7 −1.4 to 2.9 0.50
There is also a concern for increased risk of injuring the vas deferens
Missing 1.8 0.2 to 3.4 0.03
Complications/concurrent surgeries
or the spermatic vessels during laparoscopic repairs. In fact, performing
Hydrocele 0.3 −1.5 to 2.1 0.75 a complete ligation of the hernia sac laparoscopically without damaging
Incarcerated/Obstructed/ Gangrene 2.7 −0.4 to 5.7 0.09 these structures has been one of the major hurdles in developing a
ASA class laparoscopic technique with minimal incisions [16]. We have found,
I 0.0 Ref.
however, that laparoscopy allowed us to more clearly visualize these
II 3.4 1.8 to 5.1 b.0001
III 15.8 11.8 to 19.9 b.0001 structures. Our technique minimized manipulation and trauma to the
a vas and the vessels. We also used hydrodissection to completely
The multilevel regression model was adjusted for all the variables shown in the table
as well as surgeon using a random effect. The percent of remaining variation attributed to circumferentially ligate the sac to avoid any skipped areas. No diagnosis
the surgeon was 36%. We also examined year of surgery, but it was not associated with of injury to the vas deferens or the spermatic vessels and no diagnosis
surgical time. Before adjustment, the incision time averaged 36 min (standard deviation, of testicular atrophy were recorded in a patient who received the lapa-
17 min) for open-unilateral and open-explore, 56 min for open-bilateral, 25 min for roscopic technique.
lap-unilateral, and 31 min for lap-bilateral.
One reoperation under general anesthesia was performed to drain the
infection, and it followed an open repair. In contrast, laparoscopic repair
laparoscopic surgery was more often associated with bilateral repair was associated with a greater frequency of wound infections. Some of
(38%) than was open surgery (17%). These results are similar to those these wound infections in the laparoscopy group were suture granulomas
of a 2014 meta-analysis [5] and other reports (Table 5), in which 20%– and sutures abscesses. None required operative drainage. Nonabsorbable
40% of patients had contralateral patent processus, similar to the 37% ties were used to ligate the hernia sac given past studies indicating a
of laparoscopy patients who received bilateral surgery in the present higher rate of recurrence using absorbable sutures. Consideration should
study [6–12]. Similarly, the recurrence rate we observed with laparo- be given in the future to possibly using absorbable sutures using this tech-
scopic surgery was similar to rates reported in the literature for various nique and reviewing the rate of recurrence and wound problems.
laparoscopic techniques of 1% to 4% (Table 5) [6–13]. This study had limitations beyond its low power to detect adverse
It has been argued that laparoscopic identification of contralateral events, which is common to most studies of surgical complications. In
patent processus is a poor indicator of future contralateral hernia [14]. general, observational studies are prone to confounding, in which
However, in the present study, laparoscopic patients who received patients selected for one surgical technique differ in ways that cannot
bilateral surgery had reduced risk of a future contralateral recurrence. be measured and for which statistical adjustment cannot be performed.

Table 5
Reports of outcomes following laparoscopic pediatric inguinal hernia repair among clinical series.

Operative time

Investigator and year Study period Country No. of laparoscopic Detection of contralateral Unilateral Bilateral Duration of follow-up, Recurrence, %
patients defects, % months

Chong (present study) 2010–2016 U.S.A. 548 37 25 31 31 0.2

Cui 2016 2011–2013 China 236 39 11 19 – 0
Li 2014 2010–2013 China 207 – 18 26 17 0.5
Liu 2014 2010–2012 China 130 20 – – 12 0
Shen 2010 2006–2009 China 86 28 11 16 15 0
Xu 2013 2008–2012 China 536 43 12 19 6 2
Shalaby 2018 2000–2015 Egypt 1284 23 – – – 1
Parelkar 2010 1999–2009 India 437 20 23 29 – 2.4
Schier 2006 1999–2005 Germany 542 17 – – 39 4.1
2144 A.J. Chong et al. / Journal of Pediatric Surgery 54 (2019) 2138–2144
Although this is a general concern, in the present analysis, the approach
to surgery was driven by surgeon preference, which minimizes any
effect of selection bias. In addition, although the study included 17 sur-
geons, with 5 performing laparoscopic repairs, the findings may not be
entirely generalizable to other surgeons, particularly those whose lapa-
roscopic technique varies from the technique used in our system.
4. Conclusions
This large study with long-term follow-up of both open and innova-
tive laparoscopic pediatric inguinal hernia repair gave evidence that the
laparoscopic technique offered a more favorable risk–benefit profile
than the open approach. The rate of recurrence was low and equivalent,
operative times were reduced, and fewer children required a second
operation for a metachronous contralateral hernia repair.
Declaration of interest
None on behalf of all authors
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