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Laparoscopic evaluation for a contralateral patent processus vaginalis: part III
E B Yerkes1, J W Brock, G W Holcomb
1Division of Pediatric Urology, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2765, USA.
Insights
A contralateral patent processus vaginalis (CPPV) is surprisingly common in children with inguinal hernias. Diagnostic laparoscopy effectively evaluates the contralateral inguinal anatomy, preventing unnecessary surgery.
Area of Science:
- Pediatric Surgery
- Surgical Innovation
- Diagnostic Imaging
Background:
- Inguinal hernias are common in children.
- Contralateral inguinal anatomy evaluation is crucial.
- Minimally invasive techniques are sought for diagnosis.
Purpose of the Study:
- To investigate the role of diagnostic laparoscopy in evaluating contralateral inguinal anatomy in children with inguinal hernias.
- To determine the incidence of contralateral patent processus vaginalis (CPPV).
Main Methods:
- Prospective study of 759 children younger than 10 years with inguinal hernias.
- Diagnostic laparoscopy performed in 627 patients to assess contralateral inguinal anatomy.
- Laparoscopy performed via umbilical or ipsilateral hernia sac approach.
Main Results:
- CPPV was found in 46% of younger children (<1 year) and 39% of older children (>1 year) with unilateral hernias.
- Laparoscopy confirmed CPPV in 46% of suspected cases and identified normal anatomy in 59% of non-suspected cases.
- 41% of patients without suspected CPPV were found to have it upon laparoscopy.
Conclusions:
- Contralateral patent processus vaginalis is unexpectedly frequent in pediatric inguinal hernia cases.
- Diagnostic laparoscopy is the optimal method for evaluating contralateral inguinal anatomy.
- Laparoscopy, especially through the ipsilateral hernia sac, reduces unnecessary exploration and future clinical contralateral hernias.
Objectives:
Between May 1, 1992 and August 1, 1996, 759 consecutive children younger than 10 years of age were evaluated and treated for known inguinal hernia. These children were participating in a prospective investigation of the potential role of diagnostic laparoscopy in the evaluation of the contralateral inguinal anatomy. The initial two series of data (parts I and II of this three-part series) were previously presented at the 1993 and 1995 American Academy of Pediatrics meetings.
Methods:
Of 759 patients, 100 children were diagnosed with bilateral inguinal hernias and therefore did not undergo laparoscopy. Thirty-two patients did not undergo laparoscopic evaluation due to technical difficulties or complicated clinical situations. The patient's contralateral inguinal region was carefully examined under anesthesia, and predictions were made regarding the likelihood of contralateral patent processus vaginalis (CPPV). Six hundred twenty-seven children underwent diagnostic laparoscopy to confirm the presence or absence of CPPV. Laparoscopy was initially exclusively performed through the umbilicus prior to repair of the known hernia, but over the last 26 months, 250 children successfully underwent laparoscopy through the ipsilateral hernia sac.
Results:
Of patients younger than 1 year of age, 114 were diagnosed with both a known unilateral hernia and CPPV, whereas 132 had a unilateral hernia only (46% versus 54%). Among children older than 1 year of age, 148 (39%) were diagnosed with unilateral hernia and CPPV, and 233 (61%) were diagnosed with a unilateral hernia alone. After examination under anesthesia, 233 of the 627 patients were suspected of having a CPPV, and 107 were confirmed at laparoscopy (46%). The remaining 394 patients were not believed to have a CPPV. Normal inguinal anatomy was confirmed in 234 patients (59%), but 160 patients were found at laparoscopy to have a CPPV (41%).
Conclusions:
A contralateral patent processus vaginalis may be present in a surprising number of young patients being evaluated for a known inguinal hernia. Laparoscopy can be performed without a separate incision when the ipsilateral hernia sac is of sufficient width to allow passage of the scope. Laparoscopy is the best method for evaluating the contralateral inguinal region, particularly in younger children, as it prevents unnecessary inguinal exploration and it decreases the risk that the child will later present with a clinical contralateral hernia.