NEW ORLEANS, LA USA (UroToday.com) - Dr. Nima Baradaran presented the experience of the Medical University of South Carolina with laparoscopic intra-abdominal patent processes vaginalis ligation (LIPPL). Although pediatric surgeons have commonly reported a laparoscopic approach to the pediatric inguinal hernia or communicating hydrocele, this method has been slow to catch on in the pediatric urology community.
A total of 84 patients and 125 hernias underwent LIPPL at a mean age of 24 months between 2012 and 2014. The procedure is performed with a 5mm trocar through the umbilicus for camera access. A grasper instrument is inserted percutaneously via a stab wound in the mid-clavicular line of the abdomen. The internal ring is ligated using percutaneous insertion of a 22-gauge spinal needle loaded with a 2-0 or 3-0 Prolene (size based on patient age). The needle is advanced lateral and medial to the internal ring under the peritoneum and over the gonadal vessels and vas deferens, creating a purse string around the patent processes vaginalis (PPV) with the Prolene, which is then secured extra-corporeally.
Initial presentation of the PPV was unilateral in 73, bilateral in 10, and a PPV was identified on the contralateral side during unilateral surgery in 33 cases. Median operating time was 35 (20-78) and 43 (27-85) minutes for unilateral and bilateral cases, respectively. There were no intraoperative complications. Median follow-up was 4.9 months with a median time since surgery of 13 months. There were no hernia recurrences or surgical site infections during follow-up. One patient had a suture granuloma that required excision. One patient had minor testicular ascent, and 2 patients had residual small non-communicating hydroceles; all three are being observed conservatively.
This abstract generated a small amount of controversy due to the large number of contralateral hernia repairs that were performed. The authors acknowledged that there is evidence in the literature to suggest that not all of these may be clinically significant. However, the authors felt it was more appropriate to proceed with a repair when gas was able to pass into the scrotum via a contralateral PPV, especially with the current controversy surrounding anesthesia neurotoxicity, which may be related to multiple exposures. Repairing a contralateral PPV only added 10 minutes to the case, on average. Furthermore, the LIPPL approach provides an added advantage of ensuring that one is operating on the correct side when the clinical exam does not corroborate the parent history. The LIPPL technique appears to be safe with minimal risk of recurrence and a low rate of complications. The long-term experience will be informative and will help to validate this initial report.
Presented by Nima Baradaran at the American Urological Association (AUA) Annual Meeting - May 15 - 19, 2015 - New Orleans, LA USA
University of South Carolina, Charleston, SC
Reported by Michaella M. Prasad, MD (Medical University of South Carolina, Charleston, SC USA), medical writer for UroToday.com