Seminars in Pediatric Surgery 25 (2016) 232–240

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Seminars in Pediatric Surgery

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

Current concepts in the management of inguinal hernia and hydrocele

in pediatric patients in laparoscopic era
Ciro Esposito, MD, PhDa,n, Maria Escolino, MDa, Francesco Turrà, MDa,
Agnese Roberti, MDa, Mariapina Cerulo, MDa, Alessandra Farina, MDa,
Simona Caiazzo, MDb, Giuseppe Cortese, MDb, Giuseppe Servillo, MDb,
Alessandro Settimi, MDa
a
Department of Translational Medical Sciences, Federico II University, Via Pansini 5, Naples, Italy 80131
b
Department of Anesthesiology, Federico II University, Naples, Italy

a r t i c l e i n f o abstract

The surgical repair of inguinal hernia and hydrocele is one of the most common operations performed in
Keywords: pediatric surgery practice. This article reviews current concepts in the management of inguinal hernia
Inguinal hernia and hydrocele based on the recent literature and the authors' experience. We describe the principles of
Hydrocele clinical assessment and anesthetic management of children undergoing repair of inguinal hernia,
Children underlining the differences between an inguinal approach and minimally invasive surgery (MIS). Other
Laparoscopy points discussed include the current management of particular aspects of these pathologies such as
Pediatric patients 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.
& 2016 Elsevier Inc. All rights reserved.

Introduction repair.8,9 In the pediatric population, the traditional inguinal

A surgical intervention for inguinal hernia (IH) and hydrocele is
one of the most common operations performed in children.1
Inguinal hernia and hydrocele have a common etiology,2 and the
surgical correction of both pathologies is similar.3 The advent of
minimal access techniques has changed conventional manage-
ment for the treatment of inguinal hernia in particular.4,5 The
incidence of inguinal hernia in children less than 18 years of age
ranges from 0.8%–4.4%.6 About 85% of children with an inguinal
hernia present with a unilateral hernia. The incidence of incarcer-
ation in untreated hernias in infants and young children varies
between 6% and 18%, but it increases to approximately 30% in
infancy.7
Bilateral inguinal hernia is significantly more common in
younger patients with an incidence of about 50% in children
younger than 1 year.8 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
n
Corresponding author.
E-mail address: ciroespo@unina.it (C. Esposito).
approach is an excellent method for hernia repair.10 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.11,12
Laparoscopic inguinal hernia repair (LH) in children was intro-
duced as an alternative to conventional open hernia repair (OH). It
was first described by Montupet in 1993.13,14 Many technical
variations have been described for LH repair,15 and can be
categorized as either intracorporeal or extracorporeal/percutane-
ous. Montupet initially described the technique of intracorporeal
repair, consisting of a purse-string suture in the peri-orificial
peritoneum at the level of the internal ring.4,14 Schier13 introduced
his technique, consisting of an “N”-shaped suture on the peri-
orificial peritoneum. Becmeur et al.16 described laparoscopic
division and resection of the hernia sac at the level of the internal
ring, with subsequent closure of the peritoneal edges. The extrac-
orporeal techniques all involve the placement of a suture circum-
ferentially around the internal ring and tying the knot using
percutaneous techniques.17
Many variations of this approach have been described. Recently,
Ostlie and Ponsky reviewed the literature,4 and stated that there
was insufficient evidence to support one approach over another.

http://dx.doi.org/10.1053/j.sempedsurg.2016.05.006
1055-8586/& 2016 Elsevier Inc. All rights reserved.
 C. Esposito et al. / Seminars in Pediatric Surgery 25 (2016) 232–240
However, the addition of the peritoneal incision intentionally
created at the level of the internal inguinal ring, as reported by
Esposito,18 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.14 The indications for, and
contraindications to LH are controversial and the superiority of LH
versus OH continues to be debated.19,20 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.1 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.21 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 region22
(Figure 1). In girls, a small mobile mass often appears in the groin
or labia, which usually represents an ovary.23 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 infants24 (Figure 2).
Anesthesia
The majority of infants and children undergoing surgical treat-
ment of hydrocele and hernia require pre-anesthetic medication
and general anesthesia.25 Separation anxiety can be quite signifi-
cant, 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,
Fig. 1. An incarcerated hernia appears as an irreducible mass in the inguinal region.
233
Fig. 2. Transillumination reveals a fluid-filled scrotum and confirms the diagnosis
of hydrocele.
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.26 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 ventila-
tory 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.27,28
Pain is a major concern in patient recovery. By providing
optimal pain management, providers can improve patient and
parent satisfaction, mobility, compliance, hemodynamic altera-
tions from stress responses, and potentially even wound healing.
Regional anesthesia is often used to supplement general anesthe-
sia and provide postoperative analgesia. The most common forms
used are regional nerve block or caudal anesthesia performed after
the induction of general anesthesia.29 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.30
234 C. Esposito et al. / Seminars in Pediatric Surgery 25 (2016) 232–240
Finally, the intranasal use of clonidine is interesting.31 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 bind-
ing of clonidine to alpha-2 adrenoceptors, hyperpolarization of
noradrenergic signaling to the ventro-lateral 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 obser-
vation 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 Sur-
geons 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 com-
ponents: (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 experi-
ence. 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 recommen-
dations to follow it, in order to protect pediatric surgeons from a
medico-legal point of view in case of complications following a
laparoscopic procedure.32,33
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.34 Infants younger
than 6 months are usually booked on a soon-available operating
list. Older children with few symptoms can be booked elec-
tively.35,36 Surgical treatment is offered for inguinal hernia to
prevent the complications of incarceration and obstruction, poten-
tially 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.37,38
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.39
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.35,36,40 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 main-
tained slowly and consistently until the hernia is reduced.41
Incarcerated hernias that are reduced have an incidence of
reincarceration as high as 15% if definitive repair is delayed more
than 5 days.42 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 Trendelen-
burg inclination to reduce the intra-abdominal pressure (IAP) and
abdominal contents. The bladder should be emptied before sur-
gery. 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 pedia-
tric 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).43 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 proce-
dure 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
 C. Esposito et al. / Seminars in Pediatric Surgery 25 (2016) 232–240
Fig. 3. Open inguinal hernia repair requires an inguinal incision and the separation of the hernia sac from the surrounding cord structures.
not already drained. This often requires an incision distally, down
to the scrotal tunica vaginalis, to release any residual fluid.39
Laparoscopic technique
The laparoscopic approach can be performed either transper-
itoneally or through a pre-peritoneal approach (using special
needles) with transperitoneal visualization.20 The transperitoneal
laparoscopic approach uses 3 ports11 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 diag-
nosis, 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 trans-umbilically. Our preferred
Fig. 4. Trocars used for laparoscopic hernia repair: (A) smooth trocars with a piece
of Nelaton catheter around the cannula to be fixed to the skin to stabilize the
trocar; (B) screw trocar.
235
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 peri-orificial
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 Schier4 can be used. These 2 techniques seem to yield similar
long-term outcomes in the literature.4 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.43,44
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 infec-
tions, particularly in infants45,46 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 advant-
age of laparoscopy is to identify and to treat a contralateral
patency of PVD, present in about 50% of patients, but increased
in younger patients.47
Laparoscopy also facilitates the identification and treatment of
other types of hernia, such as direct, femoral, and double hernias
(“hernia en pantalon”).45 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.48,49
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.50
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.51,52
Literature analysis
We performed a literature analysis using PubMed, Cochrane,
and Medline databases on all studies published during the last
236 C. Esposito et al. / Seminars in Pediatric Surgery 25 (2016) 232–240
Fig. 5. Laparoscopic hernia repair according to Montupet's technique: (A) the peri-orificial peritoneum is sectioned, (B) the needle is introduced trans-parietally, (C) a purse
string suture is placed on the peri-orificial peritoneum, and (D) the hernia defect is closed.
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,” “herniorrha-
phy,” “hernia repair,” “children,” “laparoscopic versus open her-
niorrhaphy,” “laparoscopic versus open hernia repair,”
“contralateral patency,” “complications,” “recurrence,” and “hydro-
cele.” Searches were also performed using the following limits:
clinical trials, randomized controlled trials, multicenter retrospec-
tive, 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 meas-
ures. 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 chi-squared 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 ¼ .33).
Bilateral hernia repair was significantly longer for the open
technique (46.1 min) compared to laparoscopy (30.9 min)
(P ¼ .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.13,18,41,42,50,58,63 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 ¼ .66).
Analyzing the results for infants only, the recurrence and wound
infection rates seem to be higher after OH compared to LH.45,73,76
Other complications, such as wound infection, hydrocele, iatro-
genic cryptorchidism, and testicular atrophy, were significantly
 C. Esposito et al. / Seminars in Pediatric Surgery 25 (2016) 232–240 237

Table 1
Operative time and conversion rate of hernia repair performed via the open or laparoscopic approach.

Study LH OH Operative time Operative time Operative time Operative time Conversion
unilateral LH bilateral LH unilateral OH bilateral OH rate
(min) (min) (min) (min)

Gorsler et al.5 403 14 21 1%–0.25%

Parelkar et al.7 576 23 29
Esposito et al.11 315 18.5 30.5
Schier12 712 20
Schier13 22 18 0%
Becmeur et al.16 96 25.5 35
Montupet and 47 30 0%
Esposito18
Bharathi et al.19 51 34 25.3 30.6
Alzahem20 1300 1399 10 30 14 28
Kaya et al.41 29 0%
Koivusalo et al.42 18 15 39 29 0%
Niyogi et al.43 58 248 42.2 37.5 45.1 66
Shalaby et al.44 186 13.2 25.6
Esposito et al.45 67 22
Esposito and 225 0%
Montupet50
Chan et al.53 42 44 14.7 20.1 12 26.2
Tsai et al.54 100 57 36 45.5 46 62
Misra et al..55 16 20
Kamaledeen 24 30
et al.56
Usang et al.57 104 41 58
Shalaby and 169 12.6 14 0%
Desoky58
Chan59 5 15.2 35
Chang et al.60 52 31.2
Yamoto et al.61 92 22.4 30.5
Schier et al.62 933 16 23
Oak et al.63 110 25 35 0%
Spurbeck et al.64 120 38 47
Chan et al.65 451 15.7 19.7
Bharathi et al.66 180 25 40 1%–0.9%
Dutta and 275 17
Albanese67
Lipskar et al.68 241 20.8 26.7 3%–1.7%
Montupet and 596 18.5 25.5
Esposito69
Esposito et al.70 89 11 17.5 20
Shalaby et al.71 125 125 11.1 14.1 17.3 29.1
Yerkes et al.72 627 132 44.8 51.6 42.2 48.3
Saha et al.73 30 32 47.6 57.1 28.7 33.5
Yang et al.74 1543 657 15 20 19 35
Shalaby et al.75 250 10

LH ¼ laparoscopic herniorrhaphy; OH ¼ open herniorrhaphy.

higher for OH (2.7%) compared to LH (0.9%) (P ¼ .001). In (CPVD), for an incidence of contralateral patency between 19.9%
particular, some articles reported that the incidence of complica- and 66%. It is interesting to note that the highest occurrence of
tions such as cryptorchidism and testicular atrophy was always CPVD was reported in the smaller infants73,87 (Table 2).
higher after OH than after LH (P ¼ .001).43,54,71,76,77

Rare hernias Discussion

Many uncommon hernias were identified in the LH studies,
with an incidence ranging from 0.3% to 7.2%.5,11,16,52,62,70,78,79 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
In the last 2 decades, the advent of minimally invasive surgery
has completely changed the management of pediatric inguinal
hernias.4,15 Analysis of the international literature demonstrates
ongoing discussion about the best management of an inguinal
hernia in children.14 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 compli-
cations 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.39
238 C. Esposito et al. / Seminars in Pediatric Surgery 25 (2016) 232–240

Table 2 published series to obtain adequate data for comparison purposes.

Incidence of rare hernias and contralateral patent peritoneal vaginal duct (CPVD) We found 5 studies that reported an incidence of postoperative
identified during laparoscopic hernia repair.
cryptorchidism and testicular atrophy that was higher after OH
Study Patients Rare hernias % CPVD incidence than LH (P ¼ .001).43,54,71,76,77 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
Gorsler and Schier5 403 11 DH 2.7 45.2 series compared to the OH studies.
Miltenburg et al.6 964 38.7
Parelkar et al.7 576 19.9
The advantages of LH are believed to include better visual-
Esposito et al.11 315 1 DH 0.3 39 ization of vital cord structures, which makes dissection of these
Schier13 22 57.1 structures safer. The dissection field of LH is limited to the
Becmeur et al.16 96 3 DH 3.1 7.3 peritoneal layer, with the vas deferens and cord left untouched.
Ehsan et al.47 363 39.7
Therefore, injury to the vas is not thought to occur very often.63
Esposito et al.52 1 1 AH
Tsai et al.54 100 31 This article also reinforces the usefulness of the laparoscopic
Shalaby and Desoky58 169 7.2 approach for the diagnosis of contralateral patency, which may
Schier et al.62 933 22 DH 2.3 38 avoid the need for a second surgery and anesthesic in patients
Oak et al.63 110 24.5 with a metachronous contralateral hernia. It is our feeling that
Spurbeck et al.64 120 33.3
Chan et al.65 451 39
repair of a CPVD should be offered to all families, since most desire
Lipskar et al.68 241 34 to have the CPVD repaired at the same operative setting when this
Montupet and Esposito69 596 15.9 option is offered.70,88
Esposito et al.70 89 2 DH 2.2 44.9 A meta-analysis by Miltenburg et al.6 showed that laparoscopy
Yerkes et al.72 759 42
has a sensitivity of 99.4% and a specificity of 99.5% (regardless of
Saha et al.73 30 66
Nah et al.77 63 54 patient age, sex, or side of presentation) in detection of CPVD and
Becmeur et al.78 212 3 DH 2.3 other various forms of hernia. In particular, laparoscopy provides a
2 FH clearer view to identify uncommon hernias such as a direct,
79
Schier and Klizaite 275 10 DH 7.2 femoral, or hernia “en pantalon,” allowing the appropriate oper-
5 FH
3 HP
ative technique. Zendejas et al.89 found that the factor most
1 IH þFH significantly associated with an increased risk of recurrence was
1IH þDHþFH a direct hernia; the most common cause of recurrent inguinal OH
Holcomb et al.80 518 41 is a direct hernia not recognized at the time of initial repair.
Tackett et al.81 656 8.8
Laparoscopy should eliminate this issue. As reported by Esposito
Handa et al.82 171 22.2
Steinau et al.83 368 6 et al.48 and Lima et al.,49 it is extremely easy to identify a direct
Kalantari et al.84 301 9.3 hernia during laparoscopy. In laparoscopic direct inguinal hernia
Holcomb et al.85 599 46 repair, it is important to identify and resect the hernia lipoma
Valusek et al.86 1603 40.1 (always present); then the surgeon closes the hernia defect, with
Bhatia et al.87 284 29.9
the aid of the bladder lateral ligament to reinforce the repair.
DH ¼ direct hernia; FH ¼ femoral hernia; IH ¼ indirect hernia; HP ¼ hernia en Another advantage of laparoscopy may be in the management of
pantalon; AH ¼ Amyand's hernia; CPVD ¼ contralateral patent peritoneal vaginal incarcerated hernias, especially in infants.51,52
duct. From a technical point of view, the laparoscopic approach is
easier but at the same time technically more demanding for the
Our article examined the efficacy and safety of the laparoscopic surgeon, since he or she has to be able to work in a very small
approach compared with the inguinal approach in the manage- space because of the bowel distension. Therefore, it is often useful
ment of inguinal hernia in children. The results of this article in to perform 1 or 2 enemas the day before operation and to use
regard to operative time suggested that there was no significant simethicone to empty the intestinal loops of gas, both of which
difference between the 2 approaches for unilateral inguinal allow the creation of a larger working space in the abdominal
hernias (P ¼ .33). However, in patients with a bilateral hernia, cavity.90 In small infants, true triangulation between the optical
there was a significant reduction in the operative time for LH port and the working instruments is difficult because the 2
compared with OH (P ¼ .01). The operative time did show wide operative cannulas are located higher than their usual position;
variation, depending on the technique and experience of the we prefer to position the ports at the same level as the optical
surgical team. No significant differences were observed for recur- cannula to create more distance between the ports and the
rence rates between the 2 techniques (P ¼ .66); whereas the rates internal inguinal ring. By adding these technical refinements, LH
of other complications such as wound infection, hydrocele, iatro- has become an easy approach in difficult repairs such as the
genic cryptorchidism, and testicular atrophy were significantly neonatal inguinal hernia.45 Recent literature suggests that neo-
higher for OH compared to LH (P ¼ .001). In addition, recurrence natal inguinal LH is easier and associated with fewer complications
rate and wound infections in infants were always higher after OH than open inguinal hernia repair.76 In 2 studies, similar time to full
than after LH.45,73,76 In our opinion, the higher wound infection feeds and length of hospital stay were reported in the LH and OH
rate following OH may be due to the fact that laparoscopic groups.73,77 A meta-analysis by Yang et al.74 found that LH was
incisions are located higher on the abdominal wall than inguinal superior to OH in the repair of bilateral pathology with a lower
incisions, which are inside the diaper area; for this reason, they are rate of metachronous contralateral hernia and a similar operative
subject to urine or fecal contamination, which may lead to a higher time for unilateral hernias, and similar length of hospital stay,
infection rate. In fact, studies on LH reported fewer wound recurrence, and complication rates. They also found a trend toward
infections compared with infants of similar age operated through higher recurrence rate for laparoscopic repair. A potential disad-
the inguinal approach (0% for Esposito et al.45 versus 2.3% for vantage of LH that is not able to be addressed in this article is the
Nagraj et al.76). fact that a transabdominal operation is performed with LH when
Complications after OH (vas deferens injuries, iatrogenic cryp- compared with the extraperitoneal approach with the inguinal
torchidism, and testicular atrophy) have been rarely reported in crease technique. A second disadvantage may be that the laparo-
the last 15–20 years. For this reason, we had to analyze older scopic incisions, although small, are visible above the underwear/
 C. Esposito et al. / Seminars in Pediatric Surgery 25 (2016) 232–240
bathing suit line when compared with the inguinal crease inci-
sions. 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.1,14,43
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 prospec-
tive 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.
References
1. Lau S, Lee Y, Caty M. Current management of hernias and hydroceles. Semin
Pediatr Surg. 2007;16(1):50–57.
2. Skandalakis JE, Colborn GL, Androulakis JA, Skandalakis LJ, Pemberton LB.
Embryologic and anatomic basis of inguinal herniorrhaphy. Surg Clin North Am.
1993;73(4):799–836.
3. Cogswell HD, Czerny EW. Treatment of hernias in infants and young children.
Am Surg. 1953;19(1):87–89.
4. Esposito C, Escolino M, Farina A, Settimi A. Two decade of history of laparo-
scopic pediatric inguinal hernia repair. J Laparoendosc Adv Surg Tech A. 2014;24
(9):669–670.
5. Gorsler CM, Schier F. Laparoscopic herniorrhaphy in children. Surg Endosc.
2003;17(4):571–573.
6. Miltenburg DM, Nuchtern JG, Jaksic T, Kozinetiz C, Brandt ML. Laparoscopic
evaluation of the pediatric inguinal hernia: a meta-analysis. J Pediatr Surg.
1998;33(6):874–879.
7. Parelkar SV, Oak S, Gupta R, et al. Laparoscopic inguinal hernia repair in the
pediatric age group—experience with 437 children. J Pediatr Surg. 2010;45(4):
789–792.
8. Holcomb GW 3rd, Brock JW 3rd, Morgan WM 3rd. Laparoscopic evaluation for a
contralateral patent processus vaginalis. J Pediatr Surg. 1994;29(8):970–973
[discussion 974].
9. Hata S, Takahashi Y, Nakamura T, Suzuki R, Kitada M, Shimano T. Preoperative
sonographic evaluation is a useful method of detecting contralateral patent
processus vaginalis in pediatric patients with unilateral inguinal hernia.
J Pediatr Surg. 2004;39(9):1396–1399.
10. Misra D, Hewitt G, Potts SR, Brown S, Boston VE. Inguinal herniotomy in young
infants, with emphasis on premature neonates. J Pediatr Surg. 1994;29
(11):1496–1498.
11. Esposito C, Montinaro L, Alicchio F, et al. Technical standardization of laparo-
scopic herniorrhaphy in pediatric patients. World J Surg. 2009;33(9):1846–1850.
12. Schier F. Laparoscopic inguinal hernia repair: a prospective personal series of
542 children. J Pediatr Surg. 2006;41(6):1081–1084.
13. Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg. 1998;33(10):
1495–1497.
14. Esposito C, St. Peter SD, Escolino M, Juang D, Settimi A, Holcomb GW 3rd.
Laparoscopic versus open inguinal hernia repair in pediatric patients: a
systematic review. J Laparoendosc Adv Surg Tech A. 2014;24(11):811–818.
15. Ostlie DJ, Ponsky TA. Technical options of the laparoscopic pediatric inguinal
hernia repair. J Laparoendosc Adv Surg Tech A. 2014;24(3):194–198.
16. Becmeur F, Philippe P, Lemandat-Schultz A, et al. A continuous series of 96
laparoscopic inguinal hernia repairs in children by a new technique. Surg
Endosc. 2004;18(12):1738–1741.
239
17. Takehara H, Yakabe S, Kameoka K. Laparoscopic percutaneous extraperitoneal
closure for inguinal hernia in children: clinical outcome of 972 repairs done in
3 pediatric surgical institutions. J Pediatr Surg. 2006;41(12):1999–2003.
18. Montupet P, Esposito C. Laparoscopic treatment of congenital inguinal hernia in
children. J Pediatr Surg. 1999;34(3):420–423.
19. Bharathi RS, Arora M, Baskaran V. Pediatric inguinal hernia: laparoscopic versus
open surgery. JSLS. 2008;12(3):277–281.
20. Alzahem A. Laparoscopic versus open inguinal herniotomy in infants and
children: a meta-analysis. Pediatr Surg Int. 2011;27(6):605–612.
21. Brisson P, Patel H, Feins NJ. Cremasteric muscle hypertrophy accompanies
inguinal hernias in children. J Pediatr Surg. 1999;34(9):1320–1321.
22. Coren ME, Madden NP, Haddad M, Lissauer TJ. Incarcerated inguinal hernia in
premature babies—a report of two cases. Acta Paediatr. 2001;90(4):453–454.
23. Boley SJ, Cahn D, Lauer T, Weinberg G, Kleinhaus S. The irreducible ovary: a true
emergency. J Pediatr Surg. 1991;26(9):1035–1038.
24. Madden N. Testis, hydrocele, and varicocele. Essent Paediatr Urol. 2007;
1691:130.
25. Wiener ES, Touloukian RJ, Rodgers BM, et al. Hernia survey of the section on
surgery of the American Academy of Pediatrics. J Pediatr Surg. 1996;31(8):
1166–1169.
26. Patel A, Clark SR, Schiffmiller M, Schoenberg C, Tewfik G. A survey of practice
patterns in the use of laryngeal mask by pediatric anesthesiologists. Pediatr
Anesth. 2015;25(11):1127–1131.
27. Jones LJ, Craven PD, Lakkundi A, Foster JP, Badawi N. Regional (spinal, epidural,
caudal) versus general anaesthesia in preterm infants undergoing
inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev. 2015;6:
CD003669.
28. Frumiento C, Abajian JC, Vane DW. Spinal anesthesia for preterm infants
undergoing inguinal hernia repair. Arch Surg. 2000;135(4):445–451.
29. Broadman LM. Use of spinal or continuous caudal anesthesia for inguinal
hernia repair in premature infants: are there advantages. Reg Anesth. 1996;21
(suppl 6):108–113.
30. Morrison K, Herbst K, Corbett S, Herndon CD. Pain management practice patterns
for common pediatric urology procedures. Urology. 2014;83(1):206–210.
31. Jing Wang G, Belley-Cotè E, Burry L, et al. Clonidine for sedation in the critically
ill: a systematic review and meta-analysis (protocol). Syst Rev. 2015;4:154.
32. Esposito C, Escolino M, Saxena A, et al. European Society of Pediatric Endo-
scopic Surgeons (ESPES) guidelines for training program in pediatric minimally
invasive surgery. Pediatr Surg Int. 2015;31(4):367–373.
33. Esposito C, Escolino M, Draghici I, et al. Training models in pediatric minimally
invasive surgery: rabbit model versus porcine model: a comparative study.
J Laparoendosc Adv Surg Tech A. 2016;26(1):79–84.
34. Groff DB, Nagaraj HS, Pietsch JB. Inguinal hernias in premature infants operated
on before discharge from the neonatal intensive care unit. Arch Surg. 1985;120
(8):962–963.
35. Gonzalez Santacruz M, Mira Navarro J, Encinas Goenechea A, Garcia Ceballos A,
Sanchez Zaplana H, Jimenez Cobo B. Low prevalence of complications of
delayed herniotomy in the extremely premature infant. Acta Paediatr.
2004;93(1):94–98.
36. Krieger NR, Shochat SJ, McGowan V, Hartman GE. Early hernia repair in the
premature infant: long-term follow-up. J Pediatr Surg. 1994;29(8):978–982
[discussion 981–982].
37. Rajput A, Gauderer MW, Hack M. Inguinal hernias in very low birth weight
infants: incidence and timing of repair. J Pediatr Surg. 1992;27(10):1322–1324.
38. Uemura S, Woodward AA, Amerena R, Drew J. Early repair of inguinal hernia in
premature babies. Pediatr Surg Int. 1999;15(1):36–39.
39. Wilson JM, Aaronson DS, Schrader R, Baskin LS. Hydrocele in the pediatric
patient: inguinal or scrotal approach? J Urol. 2008;180(suppl 4):1724–1727.
40. Chen LE, Zamakhshary M, Foglia RP, Coplen DE, Langer JC. Impact of wait time
on outcome for inguinal hernia repair in infants. Pediatr Surg Int. 2009;25
(3):223–227.
41. Kaya M, Huckstedt T, Schier F. Laparoscopic approach to incarcerated inguinal
hernia in children. J Pediatr Surg. 2006;41(3):567–569.
42. Koivusalo A, Pakarinen MP, Rintala RJ. Laparoscopic herniorrhaphy after
manual reduction of incarcerated inguinal hernia. Surg Endosc. 2007;21(12):
2147–2149.
43. Niyogi A, Tahim AS, Sherwood WJ, et al. A comparative study examining open
inguinal herniotomy with and without hernioscopy to laparoscopic inguinal
hernia repair in a pediatric population. Pediatr Surg Int. 2010;26(4):387–392.
44. Shalaby RY, Fawy M, Soliman SM, Dorgham A. A new simplified technique for
needlescopic inguinal herniorrhaphy in children. J Pediatr Surg. 2006;41(4):
863–867.
45. Esposito C, Turial S, Escolino M, et al. Laparoscopic inguinal hernia repair in
premature babies weighing 3 kg or less. Pediatr Surg Int. 2012;28(10):989–992.
46. Esposito C, Montinaro L, Alicchio F, Savanelli A, Armenise T, Settimi A.
Laparoscopic treatment of inguinal hernia in the first year of life. J Laparoendosc
Adv Surg Tech A. 2010;20(5):473–476.
47. Toufique Ehsan M, Ng AT, Chung PH, Wong KK, Tam PK. Laparoscopic
hernioplasties in children: the implication on contralateral groin exploration
for unilateral inguinal hernias. Pediatr Surg Int. 2009;25(9):759–762.
48. Esposito C, Alicchio F, Giurin I, Castellano M, Settimi A. Technical stand-
ardization of laparoscopic direct hernia repair in pediatric patients. J Lapa-
roendosc Adv Surg Tech A. 2012;22(1):113–116.
49. Lima M, Ruggeri G, Domini M, et al. Laparoscopic treatment of bilateral direct
inguinal hernia by using the vesical ligament as an autologous patch. Pediatr
Endosurg Innov Techn. 2002;6:277–279.
240 C. Esposito et al. / Seminars in Pediatric Surgery 25 (2016) 232–240
50. Esposito C, Montupet P. Laparoscopic treatment of recurrent inguinal hernia in
children. Pediatr Surg Int. 1998;14(3):182–184.
51. Esposito C, Turial S, Alicchio F, et al. Laparoscopic repair of incarcerated inguinal
hernia. A safe and effective procedure to adopt in children. Hernia. 2013;17(2):
235–239.
52. Esposito C, Iaquinto M, Escolino M, Settimi A. Laparoscopic management of a
newborn with a right Amyand's hernia and a left incarcerated inguinal hernia.
Afr J Paediatr Surg. 2013;10(1):35–37.
53. Chan KL, Hui WC, Tam PK. Prospective randomized single-center, single-blind
comparison of laparoscopic vs open repair of pediatric inguinal hernia. Surg
Endosc. 2005;19(7):927–932.
54. Tsai YC, Wu CC, Yang SSD. Open versus minilaparoscopic herniorrhaphy for
children: a prospective comparative trial with midterm follow-up evaluation.
Surg Endosc. 2010;24(1):21–24.
55. Misra D, Hewitt G, Potts SR, Brown S, Boston VE. Transperitoneal closure of the
internal ring in incarcerated infantile inguinal hernias. J Pediatr Surg. 1995;130
(1):95–96.
56. Kamaledeen SAE, Shanbhogue LK. Preperitoneal approach for incarcerated
inguinal hernia in children. J Pediatr Surg. 1997;32(12):1715–1716.
57. Usang UE, Sowande OA, Adejuyigbe O, Bakare TI, Ademuyiwa OA. Day case
inguinal hernia surgery in Nigerian children: prospective study. Afr J Paediatr
Surg. 2008;5(2):76–78.
58. Shalaby R, Desoky A. Needlescopic inguinal hernia repair in children. Pediatr
Surg Int. 2002;18(2-3):13–16.
59. Chan KL. Laparoscopic repair of recurrent childhood inguinal hernias after open
herniotomy. Hernia. 2007;11(1):37–40.
60. Chang YT, Wang JY, Lee JY, Chiou CS, Hsieh JS. One-trocar laparoscopic
transperitoneal closure of inguinal hernia in children. World J Surg. 2008;32
(11):2459–2463.
61. Yamoto M, Morotomi Y, Yamamoto M, Suehiro S. Single incision laparoscopic
percutaneous extraperitoneal closure for inguinal hernia in children: an initial
report. Surg Endosc. 2011;25(5):1531–1534.
62. Schier F, Montupet P, Esposito C. Laparoscopic inguinal herniorrhaphy in
children: a three-center experience with 933 repairs. J Pediatr Surg. 2002;37(3):
395–397.
63. Oak S, Parelkar S, Agarwal P, et al. Laparoscopic surgery of inguinal hernia in
children—experience with 110 repairs. Indian J Surg. 2004;66:70–74.
64. Spurbeck WW, Prasad R, Lobe TE. Two-year experience with minimally
invasive herniorrhaphy in children. Surg Endosc. 2005;19(4):551–553.
65. 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;42
(12):1993–1997.
66. Bharathi RS, Dabas AK, Arora M, Baskaran V. Laparoscopic ligation of internal
ring—three ports versus single-port technique: are working ports necessary.
J Laparoendosc Adv Surg Tech. 2008;18(6):891–894.
67. Dutta S, Albanese C. Transcutaneous laparoscopic hernia repair in children: a
prospective review of 275 hernia repairs with minimum 2-year follow-up. Surg
Endosc. 2009;23(1):103–107.
68. Lipskar AM, Soffer SZ, Glick RD, Rosen NG, Levitt MA, Hong AR. Laparoscopic
inguinal hernia inversion and ligation in female children: a review of 173
consecutive cases at a single institution. J Pediatr Surg. 2010;45(6):1370–1374.
69. Montupet P, Esposito C. Fifteen years experience in laparoscopic inguinal
hernia repair in pediatric patients. Results and considerations on a debated
procedure. Surg Endosc. 2011;25(2):450–453.
70. Esposito C, Giurin I, Alicchio F, et al. Unilateral inguinal hernia: laparoscopic or
inguinal approach. Decision making strategy: a prospective study. Eur J Pediatr.
2012;171(6):989–991.
71. Shalaby R, Ibrahem R, Shahin M, et al. Laparoscopic hernia repair versus open
herniotomy in children: a controlled randomized study. Minim Invasive Surg.
2012;2012:484135.
72. Yerkes EB, Brock JW 3rd, Holcomb GW 3rd, Morgan WM 3rd. Laparoscopic
evaluation for a contralateral patent processus vaginalis: part III. Urology.
1998;51(3):480–483.
73. Saha N, Biswas I, Rahman MA, Islam MK. Surgical outcome of laparoscopic and
open surgery of pediatric inguinal hernia. Mymensingh Med J. 2013;22
(2):232–236.
74. Yang C, Zhang H, Pu J, Mei H, Zheng L, Tong Q. Laparoscopic vs open
herniorrhaphy in the management of pediatric inguinal hernia: a systemic
review and meta-analysis. J Pediatr Surg. 2011;46(9):1824–1834.
75. Shalaby R, Shams AM, Mohamed S, el-Leathy M, Ibrahem M, Alsaed G. Two-
trocar needlescopic approach to incarcerated inguinal hernia in children.
J Pediatr Surg. 2007;42(7):1259–1262.
76. Nagraj S, Sinha S, Grant H, Lakhoo K, Hitchcock R, Johnson P. The incidence of
complications following primary inguinal herniotomy in babies weighing 5 kg
or less. Pediatr Surg Int. 2006;22(6):500–502.
77. Nah SA, Giacomello L, Eaton S, et al. Surgical repair of incarcerated inguinal
hernia in children: laparoscopic or open? Eur J Pediatr Surg. 2011;21(1):8–11.
78. Becmeur F, Dimitriu C, Lacreuse I, et al. Laparoscopic treatment of congenital
inguinal hernias in children (212 patients). Arch Pediatr. 2007;14(8):985–988.
79. Schier F, Klizaite J. Rare inguinal hernia forms in children. Pediatr Surg Int.
2004;20(10):748–752.
80. Holcomb GW, Morgan WM, Brock JW. Laparoscopic evaluation for contralateral
patent processus vaginalis. J Pediatr Surg. 1996;31(8):1170–1173.
81. Tackett LD, Breuer CK, Luks FI, et al. Incidence of contralateral inguinal hernia: a
prospective analysis. J Pediatr Surg. 1999;34(5):684–687 [discussion 687–688].
82. Handa R, Kale R, Harjai M. Incidental inguinal hernias on laparoscopy. Asian J
Surg. 2006;29(1):28–30.
83. Steinau G, Bö hm G, Vaassen P, et al. Contralateral inguinal hernia in childhood
and youth: which child will develop a contralateral inguinal hernia. Hernia.
2008;12(6):631–634.
84. Kalantari M, Shirgir S, Ahmadi J, Zanjani A, Soltani AE. Inguinal hernia and
occurrence on the other side: a prospective analysis in Iran. Hernia. 2009;13
(1):41–43.
85. Holcomb GW 3rd, Morgan WM 3rd, Brock JW 3rd. Laparoscopic evaluation for
contralateral patent processus vaginalis: part II. J Pediatr Surg. 1996;31:
1170–1173.
86. Valusek PA, Spilde TL, Ostlie DJ, et al. Laparoscopic evaluation for contralateral
patent processus vaginalis in children with unilateral inguinal hernia.
J Laparoendosc Adv Surg Tech A. 2006;16(6):650–653.
87. Bhatia AM, Gow KW, Heiss KF, et al. Is the use of laparoscopy to determine
presence of contralateral patent processus vaginalis justified in children greater
than 2 years of age. J Pediatr Surg. 2004;39(5):778–781.
88. Holcomb GW III, Miller KA, Chaignaud BE, Shew SB, Ostlie DJ. The parental
perspective regarding the contralateral inguinal region in a child with a known
unilateral inguinal hernia. J Pediatr Surg. 2004;39(3):480–482, discussion 480-
482.
89. Zendejas B, Onkendi EO, Brahmbhatt RD, Lohse CM, Greenlee SM, Farley DR.
Long-term outcomes of laparoscopic totally extraperitoneal inguinal hernia
repairs performed by supervised surgical trainees. Am J Surg. 2011;201
(3):379–384.
90. Esposito C, Escolino M, Farina A, et al. The role of bowel preparation to optimize
working space in laparoscopic inguinal hernia repair in infants. J Pediatr Surg.
2014;49(10):1536–1537.