Laparoscopy through the open ipsilateral sac to evaluate presence of contralateral hernia.
OBJECTIVE
Laparoscopic evaluation of the contralateral side (LECS) in children with unilateral inguinal hernia (UIH) has been criticized because of the abdominal trocar risk and costs. LECS was modified to avoid abdominal trocar insertion by using the open hernia sac for instrumentation (OHLECS). This study was performed to determine the utility, safety, and effectiveness of this technique.


METHODS
During a 15-month period, 80 children with unilateral hernia underwent attempted OHLECS. All ordinarily would have undergone open contralateral exploration. The indications were UIH in boys < or = 2 years of age and girls < or = 4 years of age (n = 53) or high clinical suspicion (but not certainty) of contralateral hernia in older children with UIH (n = 27). Endotracheal intubation was not used unless otherwise indicated. Reusable 3-mm blunt trocars and 3-mm 30 degrees or 70 degrees laparoscopes were employed, with and 6 to 8 mm of insufflation pressure. No urethral catheter was used. The ipsilateral hernia sac was dissected, opened, and instrumented, and the contralateral side was evaluated for patency. Concurrent external palpation of the contralateral inguinal canal is an important diagnostic adjunct. Positive results were visible patency of processus vaginalis or bubbles or fluid and/or gas expressed from the processus by palpation. Only if the evaluation was positive was contralateral incision and repair performed. OHLECS added no more than 2 minutes of operating time. The operating room cost is similar to that of opening the contralateral side. Only reusable laparoscopic instruments are used, and less operating time, anesthetic time, suture material, and dressings are required if the contralateral side is not opened.


RESULTS
In 10 patients (all < 6 months old) OHLECS was aborted because the hernia sac was smaller than 3 mm at the internal ring. OHLECS was successful in 70 (88%) patients-56 boys and 14 girls, aged 2 mo to 12 years (mean, 2.6 years). The presenting hernia was right-sided in 46 (66%) and left-sided in 24 (34%). Overall, 43 (61%) OHLECS results were negative and 27 (39%) were positive. The OHLECS results were positive for 22 (39%) boys and 5 (36%) girls. Their mean age was 1.9 years (range, 2 months to 10 years). There were no false-positives and one false-negative. There have been no complications during follow-up (mean, 1.14 years; range, 6 months to 2 years). No additional costs were incurred because nondisposable equipment was used.


CONCLUSIONS
Laparoscopic evaluation of the contralateral side via the open ipsilateral hernia sac is feasible, quick, safe, cost effective, and requires no additional incisions. The rate of positive findings is comparable with that of open exploration. Long-term follow-up is required to determine the ultimate effectiveness of the technique.
Wulkan
M L
ML
Department of Pediatric Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA 15213, USA.
Wiener
E S
ES
VanBalen
N
N
Vescio
P
P
D002648:Child; D002675:Child, Preschool; D017743:Equipment Reuse; D005260:Female; D005500:Follow-Up Studies; D006552:Hernia, Inguinal / Q000175:diagnosis* / Q000601:surgery*; D017721:Hospital Costs; D006801:Humans; D007223:Infant; D020706:Laparoscopes; D010535:Laparoscopy / Q000191:economics / Q000379:methods*; D008297:Male; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013997:Time Factors; D016896:Treatment Outcome