Overview
Definition:
Laparoscopic hernia repair in infants refers to the minimally invasive surgical technique used to correct hernias, most commonly inguinal and umbilical hernias, in neonates and young children
It involves using a laparoscope (a small camera) and specialized instruments inserted through small incisions to visualize and repair the defect.
Epidemiology:
Inguinal hernias are common in infants, occurring in 1-5% of live births, with a higher incidence in premature infants and males
Umbilical hernias are even more common, found in up to 20% of newborns, and often resolve spontaneously
Laparoscopic repair is becoming increasingly prevalent for selected cases.
Clinical Significance:
Laparoscopic techniques offer potential benefits such as smaller incisions, reduced postoperative pain, faster recovery, and potentially lower rates of recurrence and complications like wound infection compared to open surgery
This approach is crucial for pediatric surgeons and residents preparing for examinations requiring knowledge of modern surgical practices.
Clinical Presentation
Symptoms:
Visible bulge in the groin or around the umbilicus, which may be more prominent when the infant cries, coughs, or strains
The bulge may disappear when the infant is relaxed or lying down
In incarcerated hernias, symptoms can include irritability, poor feeding, vomiting, abdominal distension, and a tender, irreducible bulge
Inguinal hernias in females can present with a palpable mass in the labia or groin.
Signs:
A reducible or irreducible bulge in the inguinal region, scrotum, or labia
Palpable mass during physical examination
In cases of incarceration, erythema and tenderness over the bulge may be present
In males, the absence of testes in the scrotum (undescended testis) can be associated with inguinal hernias, and this should be carefully assessed.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the presence of a palpable bulge in the groin or umbilical region
Imaging is usually not required unless there is diagnostic uncertainty or suspicion of complications like incarceration or strangulation
Ultrasound can be useful in specific cases.
Diagnostic Approach
History Taking:
Detailed history of the bulge's appearance, reducibility, and any associated symptoms like vomiting, fever, or feeding difficulties
Family history of hernias is also relevant
For premature infants, history of respiratory distress or other comorbidities should be noted
Red flags include acute onset of a tender, irreducible bulge, suggestive of incarceration or strangulation.
Physical Examination:
Careful examination of the inguinal regions (bilaterally), scrotum, and labia for bulges
Assess for reducibility by gentle manipulation
Palpate for tenderness and signs of inflammation
In males, assess testicular position
In infants, examination should be performed when the infant is relaxed and ideally when the bulge is evident (e.g., during crying).
Investigations:
Generally, no specific laboratory investigations are required for uncomplicated hernias
In cases of suspected incarceration or strangulation, basic blood tests like CBC and electrolytes may be ordered
Ultrasound of the groin or scrotum can confirm the diagnosis and assess for complications, especially in infants where clinical examination might be challenging.
Differential Diagnosis:
Undescended testis
Hydrocele of the cord or testis
Spermatic cord torsion
Lymphadenopathy in the groin
Femoral hernia (rare in infants)
Undiagnosed abdominal mass
Epigastric hernia
For umbilical hernias, consider omphalocele or gastroschisis in neonates.
Management
Initial Management:
For reducible hernias, surgical repair is generally recommended due to the risk of incarceration
For irreducible or incarcerated hernias, immediate reduction of the hernia is attempted under sedation
If reduction is successful and the infant is stable, elective repair is then planned
If reduction is not possible or signs of strangulation are present, urgent surgical intervention is required.
Surgical Management:
Laparoscopic inguinal hernia repair (LIHR) involves creating a pneumoperitoneum, identifying the internal inguinal ring, and ligating the sac proximally
Techniques include using a transabdominal preperitoneal (TAPP) approach or an extraperitoneal approach
Laparoscopic umbilical hernia repair involves dissecting the sac from the rectus fascia and then suturing the fascial defect
Robotic assistance may be used in select cases
Surgical indications include symptomatic or incarcerated hernias, and hernias in female infants due to the risk of ovarian incarceration.
Postoperative Care:
Pain management with appropriate analgesics
Monitoring for signs of infection, recurrence, or injury to surrounding structures
Encouraging early mobilization and feeding
Discharge typically occurs within 24 hours for uncomplicated cases
Close follow-up is essential to monitor for recurrence.
Prevention Strategies:
Meticulous surgical technique is key to preventing recurrence
Careful identification and ligation of the hernia sac at its base
Appropriate closure of the fascial defect in umbilical hernia repair
Avoiding excessive tension on sutures.
Complications
Early Complications:
Bleeding or hematoma formation
Wound infection
Injury to the vas deferens or testicular vessels (in males)
Injury to the bladder or bowel
Recurrence of the hernia
Anesthesia-related complications.
Late Complications:
Chronic pain at the incision sites
Scarring
Recurrence of the hernia
Testicular atrophy or damage (rare).
Prevention Strategies:
Thorough preoperative assessment and planning
Experienced surgical team
Careful dissection and identification of anatomical structures
Proper instrument handling
Judicious use of energy devices
Adequate closure of fascial defects
Postoperative wound care and monitoring.
Prognosis
Factors Affecting Prognosis:
The expertise of the surgical team, the timing of repair (urgent vs
elective), the presence of complications like incarceration or strangulation, and adherence to postoperative care recommendations significantly influence the prognosis.
Outcomes:
Laparoscopic hernia repair in infants generally has excellent outcomes with high success rates and low recurrence rates when performed correctly
Long-term studies report low complication rates
The majority of infants experience a full recovery with return to normal activity levels.
Follow Up:
Follow-up appointments are typically scheduled at 2-4 weeks postoperatively to assess wound healing and monitor for early complications
A longer-term follow-up may be recommended to monitor for recurrence, especially in cases with complex anatomy or previous repairs
Patients should be advised to report any new bulges or persistent pain.
Key Points
Exam Focus:
Understand the indications for laparoscopic vs
open repair
Differentiate between reducible, incarcerated, and strangulated hernias
Know the specific laparoscopic techniques for inguinal and umbilical hernias
Be aware of potential complications specific to infants and laparoscopic surgery.
Clinical Pearls:
Always perform a bilateral examination of the groins, even if the bulge is unilateral
For female infants, remember the risk of ovarian incarceration in the inguinal hernia sac
Laparoscopic repair allows for early detection of contralateral hernias, which can be repaired in the same setting if necessary.
Common Mistakes:
Failure to identify and manage an incarcerated or strangulated hernia promptly
Inadequate ligation of the hernia sac, leading to recurrence
Injury to vital structures like vas deferens or vessels
Misinterpreting clinical findings, especially in neonates.