Large inguinal hernia in infants: is laparoscopic repair the answer?

Infants with large hernias present a challenge to the pediatric surgeon. We present our experience of laparoscopic repair of large hernias in 16 infants, the youngest aged 40 days. Fifteen of the infants were younger than 18 months and one was < or = 2 years old.

Sixteen male infants with large inguinal hernias (hernia extending to the bottom of the scrotum and the diameter of the open internal ring > 2 cm on laparoscopy) underwent laparoscopic hernia repair. Diagnostic laparoscopy was performed under general anesthesia with a telescopic port at the umbilicus. If the internal ring was open, two working ports were introduced pararectally on either side. An open internal ring was considered an indication for hernia repair. The needle, carrying 3-0 nylon nonabsorbable sutures, was introduced through the groin skin at the internal inguinal ring and the internal ring was closed by taking continuous sutures to approximate the edges of the ring. The needle was then taken out through the entry point and the knot was tied extracorporeally and buried in the subcutaneous tissue. In 4 patients in the initial part of the study, intracorporeal (knot tied internally) suturing was done to close the internal ring. A contralateral repair was done if the internal ring was open.

A total of 18 repairs were performed in 16 patients: 10 had a right sided hernia, 4 had a left sided hernia, and 2 had an open contralateral ring (suggestive of contralateral patent processus vaginalis). The contents of the hernia were bowel (1 patient), omentum (3 patients), and bowel adhesions at the internal ring (1 patient). There was 1 conversion. The mean operative time was 23 minutes for unilateral repair and 29 minutes for bilateral repair. The mean follow-up was 19 months (range, 3 months to 3 years). There are no recurrences to date. There was no morbidity or mortality.

Laparoscopy is safe and feasible for repair of large inguinal hernias in infants 2 years and provides treatment of contralateral patent processus vaginalis in the same setting with no significant increase in operating time. Extracorporeal knot tying has made the procedure feasible in the limited working space available in these babies. Though there were no recurrences or post-operative hydrocele, the number of patients in the study is too small to comment on rates of recurrence or hydrocele.