A Comparative Study between the Outcome of Laparoscopic Repair and Open Repair of
Pediatric Inguinal Hernia
Sharifuzzaman M1, Ali MA2*, Hasina K3, Huq MA3 and Alam MM3
1 Department of Pediatric Surgery, Dhaka Medical College & Hospital, Bangladesh
2 Department of Pediatric Surgery, Jessore Medical College, Bangladesh
3 Dhaka Medical College & Hospital, Bangladesh
Submission: April 12, 2018; Published: May 24, 2018
*Corresponding author: Ansar Ali, Assistant Professor, Department of Pediatric Surgery, Jessore Medical College & Hospital, Jessore, Bangladesh, Email: firstname.lastname@example.org
How to cite this article: Sharifuzzaman M, Ali MA, Hasina K, Huq MA, Alam MM. A Comparative Study between the Outcome of Laparoscopic Repair and
Open Repair of Pediatric Inguinal Hernia. Adv Res Gastroentero Hepatol 2018; 9(5): 555772. DOI: 10.19080/ARGH.2018.09.555772.
Background: A hernia is a protrusion of a viscous or part of a viscous through an abnormal opening in the wall of its containing cavity. A variety of surgical technique have been discovered for pediatric inguinal hernia such as transperitoneal closure of the deep inguinal ring without opening the superficial ring and the transinguinal approach, ligation of hernial sac at the deep ring. The present study has been designed to compare the Laparoscopic repair and Open repair of pediatric inguinal hernia.
Methods:This prospective comparative interventional study was carried out in department of pediatric surgery, DMCH, Dhaka, during the period of January ‘09 to March ‘10. Total sixty patients were included in this study. Among them 30 patients in Group-L were repaired by laparoscopic procedure and another 30 patients in Group-O were repaired by open procedure. Both groups were followed-up for three months.
Results: among sixty patients early post-operative complications were almost same and there was no recurrence in any groups. It was found that pain relief is earlier in laparoscopic repair than open repair and also cosmoses. Moreover laparoscopy can detect the contralateral hernia or contralateral persistent process us vaginalis and able to repair it in the same setting.
Conclusion: laparoscopic repair of pediatric inguinal hernia seems to be a better technique than open repair with regards to early pain relief and cosmoses. By which contralateral inguinal hernia is detectable and repairable.
Keywords: Inguinal hernia; Laparoscopic repair; Open repair
A hernia is a protrusion of a viscous or part of a viscous through an abnormal opening in the wall of its containing cavity. The incidence of inguinal hernia in children range from 0.8% to 4.4% and is higher in infant . Boys are affected approximately six times more than girls. Reported sex ratio range from 3:1 to 10:1. The predominance of right sided hernia is well established (Right sided 60%, left sided- 30% and bilateral-10%).
Inguinal Hernia (IH) is one of the commonest conditions in pediatric surgical practice. The hall mark of an inguinal hernia in a child is a groin bulge, extending towards the top of scrotum, which is visible most frequently during periods of increased intra-abdominal pressure e.g. crying, straining.
A true IH will not resolve spontaneously, so surgical closure is always indicated. Because of the high risk of incarceration,
particularly in young infants, repair should be performed expeditiously. Some reports suggested that 90% of complications can be avoided if repair is undertaken within 1 month of diagnosis. Most surgeons currently recommend repair of hernia soon after diagnosis. The first who referred to hernia repair in children is credited to Celsus, who in AD 25, recommended removal of the hernial sac and testes through a scrotal incision . Pare recommended treatment of children hernia, however, the accurate description was made by Pott in 1756. Czery performed high ligation of hernial sac through the external ring 
A variety of surgical techniques have been discovered for pediatric transperitoneal closure of the deep ring .inguinal herniotomy and include the transinguinal approach, ligation of hernial sac at the deep ring without opening the superficial ring. Modern hernia surgery began in the 19th century when
an accurate understanding of the anatomy of the inguinal canal
became available. In 1912, Turner documented that high ligation
of sac was the only procedure necessary in most children.
Owing to advances in pediatric laparoscopic instrumentation
and increased experience with the technique of laparoscopy, a
number of center routinely perform laparoscopic inguinal hernia
repair in children Laparoscopic suturing and knot tying are
becoming integral part of the skill that any laparoscopist must
acquire. Intra corporeal suturing and knot tying for closure of
the inguinal hernia may need a long learning curve .
Now this procedure is more feasible, less invasive and less
painful. Moreover an advantage of this procedure is that, it
allows detection and repair of the contra lateral hernia in same
setting . In our study we planned to find out the outcome of
laparoscopic repair of inguinal hernia in terms of pain relief and
cosmesis, in the pediatric age group.
A Prospective study was planned to make a comparison
between the outcome of laparoscopic repair and open repair
of pediatric inguinal hernia. The approval of hospital ethical
committee was obtained after a detailed discussion of procedure
and study design. A total of 60 patients of inguinal hernia were
included for a period from January, 2009 to March 2010.
All patients selected for the study were divided in to two
equal groups of 30 patients in each. All surgeries were performed
after obtaining informed consent. Patients were operated on
an alternate basis i.e. one patient by laparoscopic repair and
next one by open repair of inguinal hernia. Information of
patient’s demographics, operative times, postoperative pain,
complications, recurrence and cosmoses were collected. Patients
were followed up for a period of 2 years postoperatively. All data
were plotted on Microsoft Excel and analyzed with SPSS version
In Group-L (laparoscopic repair) after antiseptic skin
preparation of anterior abdominal sterile draping was done.
A 5mm umbilical port was made by open procedure and
pneumoperitoneum was made with inflation of Carbon-di-Oxide
keeping the pressure within 8-10mm Hg. A 300 Telescope with
camera was then introduced into the abdominal cavity through
this port and the patency of process us vaginalis through internal
inguinal ring of affected side was detected. Under direct vision of
the telescope two 5mm working ports were introduced through
left and right lower abdomen. Needle holder and Maryland
forceps were introduced through these ports. A 3-0 vicryl with
cutting body needle was then introduced into the abdominal
cavity directly piercing the abdominal wall. After reducing the
sac content (if present) with the help of forceps, purse-string
suture around the internal ring was made by manipulating the
working instruments. Intra corporeal knot was made and patent
process us vaginalis was closed by tightening the knot. Further
reinforcing knots were also made. Contra lateral side was
inspected for patency of the process us vaginalis and if present,
was repaired in the same procedure described above. All ports
were then removed, gas was squeezed out, port wounds were
closed by sub cuticular suture with 3-0 or 4-0 vicryl. Sterile
dressings were then applied. Laparoscopic instrument used in
this study was made by “Karl Storz’’ (Figure 1).
In Group-O, (Open repair) after antiseptic preparation of
lower abdominal wall, a lower abdominal skin crease incision
was made on the affected side, started just lateral to the pubic
tubercle. After dissecting fascia of Camper, fascia of Scarpa and
external oblique aponurosis from superficial to deep direction,
the cremesteric muscle and fascia was swiped out by blunt
dissection with forceps. Hernial sac was identified antero medial
to the spermatic cord. It was carefully separated from testicular
vessels and vas difference (in case of male) by blunt dissection.
The sac was dissected proximally up to internal inguinal ring
indicated by appearance of extra peritoneal fat. High ligation of
neck of the sac was done at the level of the internal ring with 3-0 or 4-0 vicryl and was excised distal to the knot. Redundant
portion of sac was excised out if it was small enough or it was left
in place if it was big. Inadvertent dissection of big distal portion
of sac may results scrotal haematoma. The wound was closed in
layers. Skin was closed by sub-cuticular suture with 3-0 or 4-0
vicryl. Sterile dressing was applied (Figure 2).
This study was carried out from January 2009 to March 2010
in the Department of Pediatric Surgery, Dhaka Medical College
Hospital, Dhaka. Total 60 patients of indirect inguinal hernia
were grouped under 2 groups:
During this study period in the present series following
observations were noted:
aChi square test, bUnpaired Student’s ‘t’ test
ns = Not significant
Total 53 patients of this series were male and 7 were female, among
them in Group-L, out of 30 patients 26 were male and the rest were
female, in Group-O out of 30 patients 27 were male and the rest were
In group-L, among 30 patients right sided hernia were 21, left sided
hernia were 5 and 4 were bilateral. These bilateral hernias were
started to repair as right sided disease, but laparoscopy detected the
contra lateral sides and repaired. In group-O, among 30 patients right
sided hernia were 19, left sided hernia were 9 and bilateral were 2.
Unpaired Student’s ‘t’ test
ns = Not significant, *** = Significant at P<0.001
Patients with CHEOPS ≥4 were given specified doses of Diclofenac
Sodium, 1.5mg/kg/dose per rectal.
This was a study of pediatric hernia repair to compare
laparoscopic with open methods by conducting a prospective
study at a single institution. Multi center studies entail a certain
failure rate because of the bias of the surgeon and variations in
the level of surgical expertise across centers , whereas singlecenter
trials have the advantages of clearly defined procedures
and uniform postoperative care and analgesia  .The study on
60 patients was adequate to show a statistical difference.
Many of the initial attempts at laparoscopic hernia repair
in adults did not adhere to the established principles followed
for open surgery . For pediatric hernias, high ligation of the
hernia sac is all that is required for correction . In normal
situations, recurrence after an open procedure may be attributed
to a failure to ligate the sac high enough at the internal ring,
injury to the floor of the inguinal canal due to operative trauma,
failure to close the internal ring in girls, or postoperative wound
infection and hematoma . Our laparoscopic technique for the
repair of IH has proven to be a safe method, when performed
carefully that can prevent or avoid all these possible causes of
No recurrences were found in any of our group L patients
after a mean follow-up period of 3 months. Our group O had
no recurrences either. In the literature, the recurrence rate
for pediatric IH repair has been reported to be 1-2.5%, and
recurrences are more frequent in patients operated on by junior
surgeons or surgeons with no specific training in pediatric
surgery . There is no significant age difference in this study.
The three-port technique of the LR enables the repair of bilateral
hernias. Insertion of the three ports takes some extra time, so
for cases of unilateral hernia, the group L had a longer operative
time than the group O. However, comparatively less time was
required for repairing bilateral hernia in group L, as no extra
time for instrumental setting was required.
Laparoscopic hernia repair resolves the question of whether
contra lateral exploration is necessary in children with IH .
The rate of contra lateral patent process us vaginalis repair in
our patients was 13.33%. One may argue that not all cases of
patent process us vaginalis will develop into hernias. Open
repaired patient presenting with unilateral hernias were found
on follow-up to have developed contra lateral hernias. Because
these patients had been treated with the open technique, rather
than laparoscopic ally, there was no knowledge or treatment of
the contra lateral side. The number of contra lateral hernias in
this group may increase further with time because, pediatric inguinal hernia is the result of a patent process virginals. Though
the rate of detecting CPPV was significantly low (p<0.001) in this
study conducted with a small sample, in a large sample study it
would be significant and be established as a excellent advantage
of this procedure.
Objective behavioural and physiological parameter scoring
systems was used in the present study. Patients with CHEOPS
≥4 were given specified doses of Diclofenac Sodium, 1.5mg/
kg/dose per rectally, and the dose was repeated every 8 hours,
if necessary. There was no age difference between the two
groups. The group L required significantly lesser amount of
analgesics than group O, indicating that laparoscopic repair was
less painful. The parent’s assessments also indicated that the
children recovered faster in the group L.
The scoring system for wound appearance used in this
study was “Visual Analog Scale”(VAS). Parents of the patients
were explained and demonstrated about worst possible scar
and almost normal skin and were asked to score 0 and 100
respectively for these two extreme and other possible scores
for wound appearance in between these. Most of the parents
of the patients in the group L gave excellent scores to their
children’s wound cosmists according to Visual Analogy Scale;
this percentage was significantly higher than that for the group
O patients. Wound complications were minimal in both groups.
In conclusion, in pediatric patients with IH, the outcome of
laparoscopic repair is superior to open repair with regard to
postoperative pain, recovery, and cosmists. Laparoscopic hernia
repair also enables the detection of contra lateral hernias so that
they can be repaired in the same operative setting.