title: A selective sac extraction method: another minimally invasive procedure for inguinal hernia repair in children: a technical innovation with satisfactory surgical and cosmetic results.
abstract: OBJECTIVE
  To achieve satisfactory surgical and cosmetic results with minimal surgical invasiveness without laparoscopic assistance in childhood inguinal hernia repair, a novel technique, the selective sac extraction method (SSEM), was devised. The technical feasibility of this method was retrospectively examined.
  
  
  METHODS
  The method was applied to 162 consecutive hernia repairs in 153 patients, 79 boys and 74 girls, excluding patients with incarcerated or irreducible hernia, sliding hernia of the ovary (hernia with palpable ovary at repair), or hernia associated with an undescended testis. Hernia repair was performed by several young surgeons under the guidance of one teaching surgeon.
  
  
  RESULTS
  Patients' ages ranged from 1 month to 12 years (median, 3 years), and their body weights ranged from 2.9 to 41 kg (median, 14.4 kg). The SSEM was accomplished in 149 (92%) of 162 repairs, and lengths of incision at the end of the procedure were less than 10 mm in all repairs. The success rate was 72 (88%) of 82 repairs in male patients and 77 (96%) of 80 repairs in female patients. In the remaining 13 (8%) repairs in 13 patients, 10 males and 3 females, the procedure was converted to a conventional open method by extending the incision to 10 mm or longer. The ages of the 13 patients ranged from 1 month to 8 years (median, 3 months), being significantly younger than patients whose repair was accomplished by the SSEM (P = .006). The reason for conversion in 9 repairs was a huge or thickened sac that could not be extracted from the small incision, of which 6 involved male infants younger than 11 months. Obesity (the body mass index was 22.2 and >97th percentile for the patient's age) and thick subcutaneous tissue characteristic of early infancy were also reasons, both of which hindered the approach to the inguinal canal. Other reasons included malpositioning of the skin incision and difficulty in sac identification. The lengths of incision at the end of the 162 repairs ranged from 4.5 to 13.0 mm (median, 7.0 mm). Those in female patients, 4.5 to 11.5 mm (median, 6.5 mm), were significantly shorter than in male patients, 5.0 to 13.0 mm (median, 7.5 mm) (P < .001). The median length of the operation was 25 minutes. A follow-up interview revealed that there was no hernia recurrence with a median follow-up time of 20 months (range, 12-29 months). No postoperative complications were reported by the parents. As for the parents' satisfaction with wound cosmesis, 93% of them rated it as good or excellent.
  
  
  CONCLUSIONS
  Inguinal hernia repair with the SSEM through a minimal skin incision is technically feasible, with very satisfactory surgical and cosmetic results. As it has the potential to be a standard method for inguinal hernia repair in children, a prospective study to confirm the safety of the procedure should be carried out.
authors.affiliation: Department of Pediatric Surgery, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama 343-8555, Japan. hike@dokkyomed.ac.jp
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Ikeda
authors.forename: Masahiro
authors.initials: M
authors.lastname: Hatanaka
authors.forename: Makoto
authors.initials: M
authors.lastname: Suzuki
authors.forename: Junko
authors.initials: J
authors.lastname: Fujino
authors.forename: Kazunori
authors.initials: K
authors.lastname: Tahara
authors.forename: Yuki
authors.initials: Y
authors.lastname: Ishimaru
mesh_terms: D016009:Chi-Square Distribution; D002648:Child; D002675:Child, Preschool; D004954:Esthetics; D005260:Female; D006552:Hernia, Inguinal / Q000601:surgery*; D006801:Humans; D007223:Infant; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D016896:Treatment Outcome