BACKGROUND AND INDICATIONS
Inguinal hernia repair is the most frequent elective pediatric surgical operation performed by pediatric surgeons. The exact incidence of inguinal hernia in children is not known, but it is somewhere between 1% and 5% and is two to three times more common in premature infants. It is much more common in boys than girls. The diagnosis is almost always made by physical exam, with the palpation of a reducible mass in the inguinal region. In a child the presence of an inguinal hernia is ample indication for surgical repair. If the mass is not reducible, an urgent operation is warranted and the reduction of the bowel is performed as well as inguinal hernia repair.
The essential step in an open surgical repair is performing a high ligation of the patent processus vaginalis (PPV) while maintaining the integrity of the vas deferens and testicular vessels in boys. In girls the round ligament can be divided. Since the advent of minimally invasive techniques, surgeons have devised laparoscopic techniques that accomplish the same goals. The advantages to laparoscopic techniques is that they avoid a groin incision, or make only a very small one. The laparoscopic techniques for inguinal hernia repair differ for boys and girls; both are described here.
ANESTHESIA AND PREOPERATIVE CONSIDERATIONS
The patients are consented by their parents for possible bilateral repairs, as it is not infrequent to encounter a contralateral asymptomatic PPV. General anesthesia with endotracheal intubation is necessary for this procedure. Intravenous antibiotics are given at the discretion of the surgeon.
The patient is draped leaving their umbilicus and groin exposed. The surgeon stands opposite the side of the hernia; the assistant stands opposite the surgeon. Monitors are placed at the feet (Figure 1).
DETAILS OF PROCEDURE: BOYS
A small (3 or 5-mm) laparoscope is placed through the umbilicus after pneumoperitoneum has been established (Figure 2). Inspection for the presence of PPV is undertaken (Figure 3). It is sometimes necessary to push from the outside over the inguinal canal to express fluid or air bubbles from the patent process if there is any doubt of its presence. If doubt still remains, then the anatomy can be examined more closely once the instruments are inserted.
A small stab incision is made contralateral to the known hernia in the left or right lateral lower abdomen at the level of the anterior iliac crest. A 3-mm Hunter grasper is inserted. It is helpful if graspers are positioned so that there is a ...