Laparoscopic disconnection of the hernial sac: is it enough for the treatment of congenital inguinal hernia in children?

Laparoscopic inguinal hernia repair emerged in the 1990 s as a minimally invasive alternative to traditional open surgery, revolutionizing the management of congenital inguinal hernias (CIH) [1]. This approach was initially met with skepticism due to concerns about technical complexity and the learning curve associated with laparoscopic techniques. However, over time, it has gained widespread acceptance and is now considered the standard approach in many centers worldwide [2, 3]. Since its first introduction and with increasing surgical expertise, numerous technical modifications have been introduced, which can be categorized into three distinct conceptual approaches.

The first approach involves ligation of the hernial sac without disconnection, wherein sutures are placed to occlude the patent processus vaginalis (PPV) while keeping its continuity. This can be achieved through intracorporeal techniques, such as Montupet’s purse-string suture [4] or Schier’s “N”-shaped suture technique [5], or extracorporeal methods, as described by Patkowski “PIRS Technique” [6]. A further modification of this technique involves cauterization of the peritoneum around the internal ring (IR) before closure to create a scar, which enhances the strength of the repair “Burnia” [7]. The second approach, as proposed by Becmeur et al. [8] entails disconnection of the hernial sac with subsequent closure of the peritoneal defect. The third approach, described by Riquelme et al. [9], involves complete disconnection and resection of the hernial sac along with the parietal peritoneum surrounding the IR. In this technique, Repair of the deep ring is performed selectively, only when the ring diameter exceeds 10 mm.

These diverse approaches aimed to simplify the procedure, enhance its feasibility, and minimize both complications and recurrence rates. However, there is currently no definitive evidence to support the superiority of one technique over others [2, 7].

The aim of this study was to assess the concept of peritoneal disconnection alone without peritoneal closure in the management of inguinal hernia in children. When the deep ring is wider than 10 mm, repair of the wide deep ring will be done, again without peritoneal closure.

This study included children in the age range from 3 months to 12 years who underwent laparoscopic repair of CIH at our center from April 2021 to December 2023. Patients with the following conditions were excluded: incarcerated CIH, recurrent CIH, associated undescended testis, associated hydrocele, and chronic comorbidity such as congenital heart disease, severe pulmonary disorders, or ventriculoperitoneal shunt.

The patients were divided into two groups according to the intraoperative findings. The first group (A) included patients with a transverse internal ring diameter (IRD) of 1 cm or less who underwent laparoscopic disconnection of the hernia sac without peritoneal closure or internal ring narrowing. The other group (B) included patients with a transverse IRD measuring at more than 1 cm who underwent laparoscopic disconnection of the hernia sac and iliopubic tract repair (IPTR). The main objective of the study was to determine the recurrence rate within a year, in addition to comparing the two groups in terms of operative time, efficacy, safety, and postoperative complications.

The data were analyzed using the IBM SPSS Statistics software package, version 20.0 (©IBM Corp., Armonk, NY). The normality of continuous variables was assessed using the Shapiro-Wilk test. As the data were not normally distributed, non-parametric tests (Mann-Whitney U) were used to compare continuous variables. Where appropriate, categorical variables were analyzed using the Chi-square test or Fisher’s Exact Test. Monte Carlo simulation was applied when expected cell counts were low in multi-category comparisons. A p-value < 0.05 was considered statistically significant.

A total of 208 patients diagnosed with CIHs were included in the study and categorized into two groups based on intraoperative findings. Group A comprised 142 patients (68.3%) with a transverse internal ring diameter of 1 cm or less, while Group B included 66 patients (31.7%) with an internal ring diameter larger than 1 cm.

A synchronous contralateral PPV was detected intraoperatively in 11 patients (5.3%), including 7 males and 4 females. In these cases, the IRD was less than 1 cm. Additionally, 12 patients (5.8%) had previously undergone an open herniotomy on one side and later developed a metachronous hernia on the opposite side.

The operative time (OT), measured from skin incision to skin closure, varied significantly between the two groups. In Group A, the OT for unilateral cases ranged from 15 to 30 min, with a mean duration of 21.17 ± 5.42 min, while bilateral cases had a mean OT of 37.32 ± 4.44 min. In Group B, the OT for unilateral cases ranged from 30 to 50 min, with a mean duration of 37.61 ± 5.79 min, while bilateral cases had a mean OT of 57.41 ± 3.81 min. The increase in operative time in Group B was statistically significant for both unilateral (p < 0.001) and bilateral procedures (p < 0.001), attributed to the additional step of internal ring narrowing.

Intraoperatively, two cases (0.96%) of minor periperitoneal bleeding were recorded—one in each group. In Group A, bleeding occurred during peritoneal incision, while in Group B, it resulted from needle insertion into the abdominal cavity. Both cases stopped spontaneously without intervention. No injuries to the vas deferens, testicular vessels, or retained needles were reported.

All patients recovered uneventfully, resumed oral feeding within two hours postoperatively, and were discharged on the same day.

All patients (100%) attended the 1-week and 1-month visits in person. At 3 months and 6 months, follow-up was successfully completed for all patients, with telephone assessments accounting for 28% and 45% of visits, respectively. At 1 year, 95% of patients were successfully contacted, with 72% of these assessments conducted via telephone.

Transient inguinal edema was observed in 2 patients (1.4%) in Group A and 8 patients (12.1%) in Group B. The difference was statistically significant (p = 0.002), indicating a higher incidence of inguinal edema in patients undergoing internal ring narrowing. However, the edema resolved spontaneously in all cases within three weeks. No cases of persistent inguinal edema, hematoma, hernia recurrence, or testicular atrophy were reported in either group throughout the one-year follow-up period. Table 1.

Over the past three decades, the evolution of the laparoscopic management of CIH represents a significant advancement in surgical techniques [3]. Initial applications were exclusively diagnostic for the identification of contralateral PPV during unilateral hernia repairs [5]. The transition to therapeutic application began cautiously, initially limited to female patients to avoid potential iatrogenic injury to the delicate spermatic cord structures in males [5, 10]. With advancements in surgical expertise and instrumentation, the approach was gradually extended to male patients [4]. However, early experiences with the laparoscopic technique revealed certain drawbacks compared to traditional open repair, including higher recurrence rates, the need for multiple incisions, and longer operative durations [11‐13].

To address the issue of multiple incisions, several modifications were introduced. For example, Patkowski et al. developed the percutaneous internal ring suturing (PIRS) technique, eliminating the need for multiple ports [6]. Also, introducing smaller laparoscopic instruments and portless approaches further minimized the scar size, enhancing the cosmetic outcomes [14, 15]. Similarly, the challenge of longer operative times was mitigated as surgeons gained experience and refined their techniques, making laparoscopy comparable to or even faster than open surgery in many series [14].

The higher recurrence rates in early reports were attributed to closing the intact peritoneum, particularly in male patients, due to the difficulty of achieving a secure closure over the vas deferens and testicular vessels without leaving a “skip area.” [8, 16]. This limitation prompted the development of techniques that intentionally disrupted the peritoneum to promote scarring for more durable healing at the hernial orifice. Becmeur et al. pioneered the approach of sac disconnection with subsequent peritoneal closure, ensuring secure closure of the peritoneal defect [8]. Similarly, Ostlie and Ponsky modified the extracorporeal approach to include peritoneal cauterization, skipping the area over the vas and vessels before closure of the IR [7].

These advancements significantly reduced recurrence rates in both intracorporeal and percutaneous techniques, dropping from 3.7% in cases with intact peritoneal closure to nearly 0–1% in series where the peritoneum was transected [7, 17]. This can be explained by the distinct regenerative capabilities of peritoneum. In contrast to cutaneous wound healing, which proceeds primarily through epithelial migration from wound margins, peritoneal tissue regenerates intrinsically and forms fewer adhesions when left unsutured [18‐20]. This principle was demonstrated in a laparoscopic rabbit model, where induced peritoneal lesions left unsutured remained intact under insufflation pressures up to 35 mmHg while suture-only closures of intact peritoneum showed significantly higher mechanical failure rates under similar conditions. These results indicate that intentional peritoneal injury elicits a more durable healing response than suturing alone [21].

However, some authors have proposed that peritoneal closure may not be necessary, and sac disconnection alone may suffice, especially in cases with small IRs, even in open surgery [9, 22]. They argue that peritoneal closure, although not routinely necessary, requires advanced laparoscopic skills, increases operative time, with potential risk of injury to the vas deferens and testicular vessels [9, 23]. This perspective is supported by the observation that, in laparoscopic orchidopexy, the PPV is often disconnected but not closed, yet hernias rarely develop postoperatively [16, 24].

A new milestone was achieved when Riquelme et al. (2010) introduced the concept of “no ligation, just resection,” reporting a 0% recurrence rate over a four-year follow-up period using sac disconnection alone. However, they selectively repaired IRs with diameters larger than 10 mm [9]. Following this, multiple studies supported the safety and efficacy of sutureless repair. García-Hernández et al. (2012) applied sac disconnection regardless of IRD and reported a low recurrence rate of 0.53%, with complete sac excision down to the testis in scrotal hernias [23]. Another series in 2013 demonstrated a 0% recurrence using sac disconnection alone, with closure reserved for IRs exceeding 20 mm [25]. Similarly, Pant et al. (2014) compared sac ligation versus non-ligation and found that disconnection alone was not only simpler and faster but also had no significant difference in recurrence rates [26]. Novotny et al. (2017) reported no recurrences in girls undergoing laparoscopic sutureless repair irrespective of IRD [27].

In 2018, a stratified algorithm was proposed based on IRD, recommending sac disconnection for 4–15 mm, purse-string suturing for 15–25 mm, and muscular arch repair for defects > 25 mm or in recurrent cases. This approach significantly reduced recurrence rates from 3.7 to 1.2% [28]. Further evidence came from Galván Montaño (2018), Marte (2019), and Bukowski et al. (2020), all of whom reported no recurrences using sutureless repair across all IRD ranges [29‐31]. However, Elbatarny et al. (2020) observed higher recurrence rates with disconnection alone in IRDs > 10 mm [17], and Elsayem et al. (2022) reported that while sutureless repair was effective for IRDs < 10 mm, it had a threefold higher recurrence rate than purse-string closure in IRDs between 10 and 15 mm [32]. Most recently, Shalaby et al. (2023) reported no recurrences using a needlescopic sutureless technique for IRDs < 15 mm [33]. In the present study, a tailored surgical strategy was implemented, utilizing an IRD threshold of 10 mm to guide management. This approach resulted in no recurrences in either group at the one-year follow-up.

These findings collectively reinforce the importance of tailored surgical strategies based on IRD and defect size. While sac disconnection and sutureless repair are safe and effective for smaller hernias, larger defects require additional measures, such as purse-string sutures or muscular arch repair, to achieve durable outcomes.

Historically, numerous classification systems for adult inguinal hernias have been developed to stratify hernias based on defect size and complexity, acknowledging the limitations of a “one-size-fits-all” approach [34, 35]. Similarly, pediatric hernias demonstrate considerable variability, influenced by factors such as age, gender, IRD, pelvic depth, and local muscle conditions, necessitating individualized management strategies to optimize outcomes [25, 36]. Although a prior report by Shehata et al. [37] proposed a novel CIH classification adapted from the adult Nyhus system, it was applied in the context of open repair; however, the same scoring system remains applicable to laparoscopic techniques.

Although our study implements the same principle as Riquelme et al., there are three key differences between the two techniques. First, they advocated for complete sac resection, including the parietal peritoneum surrounding IR. This extensive dissection within the inguinal canal, as required for complete sac resection, may increase the risk of injury to the testicular vessels or vas deferens and could lead to postoperative complications such as scrotal edema and hematoma [38]. A study by Endo et al. found that edema rates correlate with the extent of dissection [39]. In contrast, our technique focuses on complete sac disconnection without resection. This approach simplifies the procedure, reduces OT, and minimizes the risk of complications while still achieving a durable repair.

Second, they employed a purse-string suture to close the IR in cases where the IRD exceeded 10 mm. This technique can be challenging and may increase the risk of injuring the vas deferens or testicular vessels if not performed carefully. In our study, we opted for IPT using one or two interrupted sutures. IPTR has been employed for decades in the open repair of adult inguinal hernias. More recently, its laparoscopic adaptation has been reported in the management of CIH, particularly in recurrent cases [40‐44]. Our findings, supported by previous studies, suggest that laparoscopic IPTR offers effective and controlled IR repair, minimizing the risk of compression or injury to the vas deferens and testicular vessels.

A potential concern with this approach is postoperative pain due to suture tension, especially given the challenges of pain assessment in pediatric patients. However, comparative studies between IPTR and high ligation have shown no significant differences in postoperative pain levels [40, 42, 43]. Careful suture placement is essential to avoid injury to the femoral branch of the genitofemoral nerve. Anatomical studies show this nerve courses caudally to the inguinal ligament in 84.0% of cases and medially toward the anterior superior iliac spine in 5.2% [45]. To mitigate this risk, sutures should be placed as close as possible to the IR [40].

The third difference is that we utilized a calibrated Maryland dissector to standardize the intraoperative measurement of the IR. This novel technique is simple, quick, and reduces the subjectivity inherent in visual estimation techniques described in earlier studies [9, 25]. Unlike approaches that involve using a thread measured externally on a ruler, our technique provides real-time practicality without the need for additional tools [17, 28]. One study employed US for IRD assessment and found no significant correlation between age and ring diameter [32]. Another group reported that US measurements were significantly smaller than those obtained laparoscopically, attributing the difference to pneumoperitoneum-induced pressure during laparoscopy. They concluded that preoperative US should not guide surgical planning, as intraoperative laparoscopic assessment offers a more accurate representation of IRD [17]. Although our method enhances reproducibility, its accuracy relies on maintaining perpendicular alignment during measurement, a limitation common to other intraoperative tools [46]. Future research could explore the use of laparoscopic calipers or imaging software to further refine this process.

The demographic characteristics of our study population, including age, sex, and hernia laterality, align with findings from previous studies on CIH. The mean age of patients in our study was 5.89 ± 4.05 years in Group A and 5.73 ± 3.91 years in Group B, consistent with the age range reported in the literature [3]. Neonates under 1 month of age were excluded from the study to mitigate the physiological risks associated with laparoscopic surgery in this vulnerable population [47]. This exclusion criterion is consistent with the methodologies of several prior studies [9, 17, 23, 48].

The use of portless instruments with small stab incisions contributed significantly to the minimally invasive nature of the laparoscopic repair. It has been shown to reduce postoperative pain and improve recovery times, as smaller incisions result in less tissue damage and inflammation [43]. Furthermore, the absence of trocars eliminates the risk of port-site hernias, a rare but potential complication associated with traditional laparoscopic techniques [46]. The cosmetic benefits of portless instruments are particularly significant in pediatric patients, as smaller incisions lead to nearly invisible scars, which is a major advantage for both parents and children [29].

In our study, synchronous contralateral PPV was detected intraoperatively in 5.3% of cases, which falls below the 10–20% incidence reported in some studies [3] but aligns with other published series [9]. This variability may be attributed to differences in patient populations and diagnostic criteria. Notably, all detected contralateral PPV in our study were managed successfully with peritoneal disconnection alone, supporting the efficacy of this technique for smaller defects [25].

The OT in our study varied significantly between the two groups, with Group B (IRD > 1 cm) requiring longer procedures due to the additional step of IPTR. The mean OT for unilateral cases in Group A was 21.17 ± 5.42 min, compared to 37.61 ± 5.79 min in Group B. These findings are consistent with previous studies, which have reported longer OT for more complex repairs involving larger IRs [7]. However, our operative times are shorter than those reported in early laparoscopic series, reflecting improvements in surgical techniques and instrumentation [2].

The selection of suture material can significantly influence surgical outcomes [49]. In our study, we employed Vicryl sutures. Some other studies have also utilized Vicryl sutures [8, 26, 44, 48], while others have chosen nonabsorbable options such as Polyester and V-Loc [9, 50, 51]. The rationale for using absorbable sutures stems from the biological healing process following deperitonealization. After exposing the raw muscular arch, wound repair occurs primarily through scar tissue formation rather than dependence on permanent foreign material retention [8, 9]. Unlike nonabsorbable sutures like Polyester or V-Loc, which remain permanently in the tissue, absorbable sutures provide temporary support during the critical healing phase and are gradually absorbed, minimizing the risk of long-term complications such as chronic pain, suture migration, or granuloma formation [52].

Intraoperative complications were rare in our study, with only two cases (0.96%) of minor periperitoneal bleeding, both of which stopped spontaneously. This low complication rate is comparable to or better than those reported in other laparoscopic series [9, 25]. Transient inguinal edema was observed in 1.4% of Group A and 12.1% of Group B, with all cases resolving spontaneously within two weeks. The higher incidence of edema in Group B is likely attributable to the additional manipulation and suture placement required for IR narrowing [39]. These findings are consistent with previous studies, which have reported edema rates ranging from 5 to 15% following laparoscopic repair, particularly in cases involving larger internal rings [28]. The absence of vas deferens or testicular vessel injuries, as well as persistent edema or hematoma, highlights the safety of our technique. Utilizing hook monopolar diathermy in cutting mode enabled precise peritoneal disconnection with minimal lateral thermal damage [39]. By creating small peritoneal rents and gently sweeping the vas and vessels away without direct diathermy contact, we ensured complete sac disconnection while preserving adjacent structures. The lateral damage caused by cutting current is much less than that caused by coagulation current.

Postoperative follow-up compliance was high (95% at one year), thereby enabling reliable ascertainment of both early and late outcomes. Given the introduction of a novel technique, an extended follow-up protocol was intentionally implemented to ensure thorough surveillance for potential complications. Attrition was minimal (5% at one year), well within accepted standards for prospective clinical studies, and was unlikely to have introduced bias into the findings, as no complications or recurrences were observed beyond 6 months among patients who completed follow-up [53]. Comparative data on one-year retention in the literature remain limited, as most published series reported recurrence outcomes without explicitly documenting long-term follow-up completion rates [9, 14, 28, 54]. Table 2..

Laparoscopic hernial sac disconnection without peritoneal closure represents a safe and effective treatment for CIH with small internal rings (< 1 cm). Avoiding peritoneal closure can reduce operative time and minimize possible injury to the vas deferens and vascular structures during suturing.

For defects larger than 1 cm, laparoscopic disconnection with repair of the muscle arch, while still avoiding peritoneal closure, is recommended to prevent hernia recurrence. However, this leads to a longer operative time and a slight increase in minor self-limiting complications.

This tailored approach can significantly reduce recurrence rates while obviating unnecessary steps that can cause morbidity. Further studies with long-term follow-up are therefore recommended.