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Comparison of intra- and extra-corporeal laparoscopic hernia repair in children: A systematic review and pooled
Sanne Maat1, Kelly Dreuning1, Stefi Nordkamp2
1Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam, Netherlands.
Insights
Extra-corporeal closure in laparoscopic paediatric inguinal hernia repair is linked to fewer recurrences and shorter operation times compared to intra-corporeal techniques. Further research is needed to compare other outcomes due to significant study heterogeneity.
Area of Science:
- Pediatric Surgery
- Minimally Invasive Surgery
Background:
- Laparoscopic surgery is widely used for pediatric inguinal hernias.
- Techniques include intra-corporeal and extra-corporeal closure, with unclear superiority.
- This study compares intra- and extra-corporeal suturing techniques.
Purpose of the Study:
- To provide evidence on the superiority of intra- versus extra-corporeal suturing techniques in laparoscopic pediatric inguinal hernia repair.
- To compare recurrence rates and operative times between the two laparoscopic techniques.
Main Methods:
- Systematic literature search of PubMed, Embase, MEDLINE, and Cochrane Library.
- Inclusion of randomized controlled trials and prospective studies comparing laparoscopic techniques.
- Pooled data analysis using a random-effects model for single-port extra-peritoneal closure versus intra-peritoneal purse string suture closure.
Main Results:
- Fifteen studies with 3680 patients were included.
- Extra-corporeal closure showed a significantly lower recurrence rate (0.6% vs 5.5%).
- Operation time was shorter for extra-corporeal repair, though pooled data was limited.
Conclusions:
- Single-port extra-corporeal closure appears superior for reducing hernia recurrence and operative time.
- No significant differences were found in peri-operative complications.
- Heterogeneity prevented definitive conclusions on other outcomes like pain or hospital stay.
Background:
Laparoscopic surgery is increasingly used to repair paediatric inguinal hernias and can be divided into intra- or extra-corporeal closing techniques. No statement regarding the superiority of one of the two techniques can be made. This study aims to provide evidence supporting the superiority of intra- or extra-corporeal suturing technique.
Methods:
A systematic literature search was conducted using PubMed, Embase, MEDLINE, and Cochrane Library databases. Randomised controlled trials and prospective studies comparing different laparoscopic techniques were eligible for inclusion. Data were pooled using a random-effects model, comparing single-port extra-peritoneal closure to intra-peritoneal purse string suture closing. Primary outcome was recurrence rate. Secondary outcomes were duration of surgery (min), peri‑ and post-operative complications (i.e. injury of spermatic vessels or spermatic cord, tuba lesions, bleeding and apnoea, haematoma/scrotal oedema, hydrocele, wound infection, iatrogenic ascent of the testis and testicular atrophy), contralateral patent processus vaginalis (CPPV) rate, post-operative pain, length of hospital stay and cosmetic appearance of the wound.
Results:
Fifteen studies (n = 3680 patients, age range 0.5-12 years, follow-up range 3-10 months) were included is this systematic review. Intra-corporeal hernia repair was performed in 738 children and extra-corporeal repair was performed in 2942 children. A pooled data analysis could only be performed for the single port extra-corporeal closing technique and the three port intra-corporeal closing technique. We found that recurrence rate was lower in the single-port extra-corporeal closing technique compared to the intra-corporeal purse suture closing technique (0.6% vs 5.5%, 95% CI 0.107 (0.024-0.477); p < 0.001). Operation time was shorter for extra-corporeal unilateral and bilateral inguinal hernia repair compared with intra-corporeal approach, but no pooled data analysis could be performed. Due to the presence of substantial heterogeneity, it was not possible to assess other outcome measures.
Conclusion:
Single-port extra-corporeal closure seems to result in less recurrent hernias and a shorter operative time compared to intra-corporeal purse suture closing technique. No difference regarding peri‑ and post-operative complications could be found and no statements regarding the length of hospital admission, post-operative pain and cosmetics could be made due to substantial heterogeneity.
Level Of Evidence:
Level II.
