Converting to Laparoscopic Inguinal Hernia Repair in Children: A Tale of a Dilemma



 

Sani Z Yamout MD, FACS

Perm J 2020;25:20.087 [Full Citation]

https://doi.org/10.7812/TPP/20.087
E-pub: 12/09/2020

“It looks like you’re still operating in the 1960s in here” my partner quips, as he looks over my shoulder into the “offensive” incision of an open inguinal hernia repair. The next day, I retort, “Wow… you’re still doing your sham operation I see!” as I look up at the screen to see him violating what I believe to be the basic premise of the traditional pediatric inguinal hernia repair with his laparoscopic technique.

Fortunately, my partners and I have the kind of relationship that allows for such jousting, even when we know they may reflect genuine disagreement.

Inguinal hernia repair is the most common elective operation performed by pediatric surgeons. Unlike the adult version of the operation, pediatric inguinal hernia repair does not involve the use of mesh to reinforce weak tissue. The goal is simply to close a hole in the abdominal wall (the internal inguinal ring) that did not close as intended before birth. While performing the operation in boys, the surgeon’s biggest concern is not injuring the vas deferens or blood supply to the testicle.

Most pediatric surgeons repair inguinal hernias using the traditional open operation described by Marcy in 1871.1 The basic steps of the open inguinal hernia repair, which have seen little if any modification since first described in the late 1800s, are as follows: Make a skin incision based on external landmarks, open the tendon-like external oblique aponeurosis, identify and dissect the hernia sac off the testicular vessels and vas deferens (DON’T GRAB THE VAS), ligate and transect the hernia sac at the level of the internal ring, close the fascia and skin, and finally, call the parents and update them.

In premature infants, the hernia sac is exceedingly thin and delicate, and the steps are occasionally modified as follows: Make a skin incision based on external landmarks, realize the incision is too high (5 mm too cephalad), re-orient yourself to the landmarks, find the external oblique aponeurosis, dissect the hernia sac off the testicular vessels and vas deferens (DON’T GRAB THE VAS), tear the hernia sac, lose the edge of the torn hernia sac, begin to sweat, find the edge of the torn hernia sac, realize the tear extends into the peritoneal cavity, sweat some more, feel nauseated, retrieve the torn sac, complete the repair, and be grateful for your experience performing several hundred straightforward open inguinal hernia repairs before you found yourself in this mess. Call the parents and update them.

In 1997, El-Gohary2 described the first laparoscopic inguinal hernia repair in a pediatric patient. Since then, various laparoscopic approaches to inguinal hernia repair have been proposed. Unlike most laparoscopic operations that build on the basic principles of the original open version, the laparoscopic inguinal hernia repair in children is a substantially different operation than the open repair. Although ligation of the hernia sac is still achieved, most versions of the laparoscopic repair violate what is felt by many to be a key requirement for success, namely, transection of the hernia sac after its ligation. This allows the internal ring to close completely.3 Simply ligating the hernia sac without transecting it results in incomplete closure of the internal ring because the retained hernia sac acts as a stent. Understandably, many pediatric surgeons believe that a retained sac results in an inferior operation with an increased risk for recurrence. This is supported by the multiple published articles that report a recurrence rate of 3% to 4%.4-6 This is at least 3 times the accepted recurrence rate of 1% with open hernia repair.7,8

I was first exposed to the laparoscopic approach to hernia repair during my pediatric surgery training in a program that was well known for advanced laparoscopic surgery. My seasoned attending surgeons advocated for laparoscopic repair of complex conditions like duodenal atresia and tracheo-esophageal fistulas, but they were skeptical of the laparoscopic approach to hernia repair, dismissing it as a gimmick, and snickering at the idea of performing one themselves. Their rule, the rule, is simple: a laparoscopic version of an operation should not have an inferior outcome. My decision was entrenched: Despite the many touted secondary benefits to the laparoscopic approach (Figure 1), the laparoscopic repair is not as good as the open repair, and I will not adopt it.

Figure 1

Figure 1. An ongoing disagreement over laparoscopic inguinal hernia repair.

When I joined The Permanente Medical Group in 2012, my partner had been repairing all pediatric inguinal hernias laparoscopically for years, using the percutaneous Tuohy needle technique. With this technique, and using a single port through the umbilicus, the peritoneum is first hydro-dissected off the vas deferens and testicular vessels. Using a clever maneuver, the hernia sac is then encircled and ligated with a permanent suture passed through a tiny stab incision in the abdominal wall using a Tuohy spinal needle. This technique results in a high ligation of the hernia sac, with no violation of the peritoneal lining near the internal ring. As with most other laparoscopic repairs, the hernia sac is not transected. Watching him do these repairs over and over, I could not help but wonder, could this truly be a better way of doing the repair? Am I just being a “dinosaur,” refusing to even consider changing?

My predicament with laparoscopic hernia repair is not unique. The practice of surgery has experienced a tremendous amount of change with the introduction of new technologies like laparoscopy, and more recently, robotic surgery. Surgeons are subsequently faced with the dilemma of deciding whether new technology and attendant techniques are worth adopting. This decision is influenced by many factors, both subjective and objective. What do the data look like? What are the patient outcomes? Can I imagine myself going against how I was trained and adopting a “gimmick”?

As I looked back at my experience contemplating the switch to laparoscopic inguinal hernia repair, I wondered if the process of adopting new technology in surgery had been studied formally. My search led me to the Unified Theory of Acceptance and Use of Technology (UTAUT), one of the theoretical models used to explain how people come to adopt and subsequently use a form of technology.9 The UTAUT has been used to evaluate the process of adoption of robots, a new technology in surgery.10 The theory also can be applied to the process of adopting a new surgical approach that breaks from the “classic” teaching, as in the case of redefining how inguinal hernias are repaired using laparoscopy. The UTAUT posits that there are 4 categories of factors that influence if and how one adopts a new form of technology. Factors can be grouped under performance expectancy, effort expectancy, social influence, and facilitating conditions.

Performance expectancy is “the degree to which an individual perceives that using a system will help him or her to attain a gain in job performance.” Is this operation as good as the open repair? Are the reported low recurrence rates real and reproducible? How will this approach to lap hernias improve my patient’s outcome? Will it make my operating room days more efficient? Effort expectancy is “the degree of ease associated with the use of the system.” How difficult is it to learn this new approach? Social influence is “the degree to which an individual perceives that important others believe he or she should use the new system.” Will pediatricians/colleagues consider me behind the times if I don’t adopt it? Will pediatricians stop referring patients to me for open hernia repair? Facilitating conditions are “the degree to which an individual believes that an organization and technical infrastructure exists to support use of the system.” Do we need to buy and maintain specialized instruments? Do we need to train surgical techs? Is there a stack of paperwork that I am going to have to fill out?

The UTAUT, however, is not comprehensive. It does not, for example, account for the emotional attachment one can develop to an operation learned as a resident, after performing it over and over and over for years; fine tuning every step until the operation became pleasant to watch, muscle memory perfected, with maximal economy of motion. Not a single unnecessary step performed. The theoretical model does not account for my fear that I will one day need to convert a lap hernia repair in a 3-kg infant into an open repair due to poor exposure because the bowel is dilated. Am I going to be able to do a good open repair in such a difficult situation when I had not done one in years? How about the next time I run into my mentor at a meeting and he asks me: “Sani… what is the most challenging operation we do?” and I can no longer answer with the traditional, and somewhat hyperbolic, response “An open inguinal hernia repair in a baby... totally underrated!.” Instead, I would have to admit that I do my inguinal hernias laparoscopically now.

For me, first and foremost, the laparoscopic operation needed to meet the performance expectancy of not being an inferior operation before I would consider it as an option. Otherwise, there were few if any other barriers to adoption other than my emotional attachment to a procedure learned and perfected years ago. The laparoscopic operation is arguably simpler to perform than the open operation (effort expectancy), more consistent in level of difficulty than the open operation, which can vary in complexity depending on the size of the patient (performance expectancy), and this operation was already being performed at our institution with full technical support (facilitating conditions).

After several years of skepticism, I eventually switched to doing my hernia repairs laparoscopically using the percutaneous Tuohy needle technique. My anecdotal observation of the low hernia recurrence rate associated with this technique was eventually supported by the results of a recent study that evaluated our group’s results with this operation, showing a recurrence rate of 0.3% after an average of 2.6 years of follow-up.11 In addition, there was a rational explanation of why this specific version of the lap hernia repair had better outcomes than others, and thus the improved recurrence rates made sense. For 4 years now, I have been doing my hernia repairs laparoscopically. As of this day, I have not regretted my switch, nor stopped hearing about it from my partner!

A few months ago, the situation I was dreading arose. I was performing a laparoscopic hernia repair on an infant and had to convert to an open repair. It had been a few years since I had last done an open hernia repair. Fortunately, my fear that I might have lost the skill I spent so many years acquiring in training did not materialize. The steps flowed, muscle memory intact, the pitfalls anticipated and avoided, and the vas was not harmed. Admittedly, it did take me a little longer to complete the repair safely than it would have 4 years ago. A small trade-off for switching to what I believe is a better approach to hernia repair in kids.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

I thank Andrea Altschuler, PhD, and Lisa Herrinton, PhD, from the Division of Research at Kaiser Permanente Northern California for their guidance, the time they spent reviewing and editing the document, and the joy and enthusiasm they both injected into daily interactions.

No sources of funding to report.

Author Affiliations

The Permanente Medical Group, Kaiser Permanente Northern California, Oakland Medical Center, Oakland, CA

Corresponding Author

Sani Z Yamout, MD, FACS ()

How to Cite this Article

Yamout SZ. Converting to laparoscopic inguinal hernia repair in children: A tale of a dilemma. Perm J 2020;25:20.087. DOI: 10.7812/TPP/20.087

References

1. Coran AG, Caldamone A, Adzick NS, et al Pediatric surgery, 7th edition. Philadelphia, PA. Elsevier; 2012

2. El-Gohary MA. Laparoscopic ligation of inguinal hernia in girls. Pediatr Endosurg Innovative Tech 1997 Jan;1(3):185-8. DOI: https://doi.org/10.1089/pei.1997.1.185

3. DeBoer A. Inguinal hernia in infants and children. AMA Arch Surg 1957 Dec;75(6):920-7. DOI: https://doi:10.1001/archsurg.1957.01280180052008, PMID:13478270

4. Schier F, Montupet P, Esposito C. Laparoscopic inguinal herniorrhaphy in children: a three-center experience with 933 repairs. J Pediatr Surg 2002 Mar;37(3):395-7. DOI: https://doi.org/10.1053/jpsu.2002.30842.

5. Chinnaswamy P, Malladi V, Jani KV, et al Laparoscopic inguinal hernia repair in children. J Soc Laparoendosc Surg 2005 Oct-Dec;9(4):393-8, PMID:16381352.

6. Schier F. Laparoscopic inguinal hernia repair-a prospective personal series of 542 children. J Pediatr Surg 2006 Jun;41(6):1081-4. DOI: https://doi.org/10.1016/j.jpedsurg.2006.02.028

7. Taylor K, Sonderman KA, Wolf LLW, et al Hernia recurrence following inguinal hernia repair in children. J Pediatr Surg 2018 Nov;53(11):2214-8. DOI: https://doi.org/10.1016/j.jpedsurg.2018.03.021

8. Jiang K-C, Chen Y-S, Yang S-D, Chen J-C, Chang S-J. Second repair of pediatric inguinal hernia: a longitudinal cohort study. Urol Sci 2019 Dec;30:1:24-9. DOI: https://doi.org/10.4103/UROS.UROS_26_18

9. Venkatesh V, Morris M, Davis, G, Davis F. User acceptance of information technology: toward a unified view. MIS Quart 2003 Sept;27(3):425-78. DOI: https://doi.org/10.2307/30036540

10. Benmessaoud C, Kharrazi H, MacDorman KF. Facilitators and barriers to adopting robotic-assisted surgery: contextualizing the unified theory of acceptance and use of technology. PLoS One 2011 Jan;6(1):e16395. https://doi.org/10.1371/journal.pone.0016395

11. Chong AJ, Fevrier HB, Herrinton LJ. Long-term follow-up of pediatric open and laparoscopic inguinal hernia repair. J Pediatr Surg 2019 Oct;54(10):2138-44. DOI: https://doi.org/10.1016/j.jpedsurg.2019.01.064

Keywords: laparoscopic inguinal hernia repair, pediatric surgery

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