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Laparoscopic Repair of Inguinal Hernias


Inguinal hernia repair is one of the most commonly performed operations in children. The open inguinal approach is an excellent method for repair but has the potential risk of injury to the spermatic cord and vas deferens, development of hematomas, wound infections, iatrogenic cryptorchidism, testicular atrophy, and recurrence. For many surgeons, laparoscopy has become the favored approach for treatment of inguinal hernias. Laparoscopy provides excellent visualization, minimal dissection of the vas deferens and spermatic vessels, comparable recurrence rates, and improved cosmesis when compared to the traditional open inguinal crease approach. The diagnosis and repair of a contralateral patent processus vaginalis (CPPV); femoral, direct, or combined hernias; and recurrent or complicated hernias can also be achieved safely and successfully via laparoscopy.

There have been several techniques described for laparoscopic inguinal hernia repairs in infants and children. These techniques can be categorized as either intracorporeal or percutaneous. This chapter describes an intracorporeal and two percutaneous techniques used to repair inguinal hernias. A recent review of the literature concluded that there is insufficient evidence to support one technique over another one. The decision between a percutaneous or an intracorporeal approach for these repairs depends on surgeon preference and experience.

Indications for Workup and Operation

The indications for a laparoscopic inguinal hernia repair are the same as for the open inguinal approach. Older children are encouraged to empty their bladder preoperatively. A full bladder does not typically hinder a laparoscopic hernia repair, but in situations where the bladder needs to be emptied, a Credé maneuver (i.e., exerting manual pressure on the bladder) can be utilized. This maneuver is especially useful in cases where a direct or femoral hernia is suspected. A urinary catheter is usually not inserted. Bowel preparation has been described in certain patient populations but is not mandatory or necessary for safe completion of this procedure.

Operative Technique

The patient is positioned on the operating table in a supine position with his or her arms tucked at his or her sides, and general anesthesia is induced. The patient is appropriately secured and padded. The patient is prepped and draped from the xiphoid to the perineum. The surgeon is usually positioned opposite to the side being repaired. The camera operator usually stands on the side opposite the surgeon, and the screen is positioned at the patient’s feet. A 5-mm port is introduced in the umbilicus using an open technique, and pneumoperitoneum is established. An average intra-abdominal pressure of 10 to 12 mm Hg is used in patients younger than 1 year of age and 12 to 15 mm Hg in older children. A 15- to 20-degree Trendelenburg inclination with or without lateral rotation of the operating table may help displace the bowel cephalad to improve exposure of the inguinal rings. The decision between a percutaneous or intracorporeal approach depends on surgeon preference and experience as there is not enough evidence to support one approach over another.

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