JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 26, Number 2, 2016 2014 IPEG Paper

ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2014.0276

Simple Purse String Laparoscopic

Versus Open Hernia Repair

Mairi Steven, MBBS, FRCS (Paed Surg), Peter Carson, MBBS, Stephen Bell, MBCHB, BMedSci (Hons),
Rebecca Ward, MBBS, and Merrill McHoney, MBBS, FRCS (Paed Surg), PhD

Abstract

Aims: To compare surgical outcomes for a simple purse string method of laparoscopic hernia (LH) repair with a
traditional open inguinal hernia (OH) repair in children in a single center.
Materials and Methods: Following ethical approval, a retrospective review of all children undergoing LH repair
from January 2010 to December 2013 versus a historic cohort of all OH repairs between January 2010 and
December 2011 was conducted. LH repair was performed by a simple purse string technique using nonabsorbable
braided suture. Groups were compared using the independent t test or the Mann–Whitney test as appropriate.
Results: One hundred three patients (23 females, 80 males) underwent LH repair over the 4-year period
compared with 151 (25 females, 126 males) OH procedures in the first 2 years. Median age in the LH group was
0.56 years (range, 0.04–14.7 years) compared with 0.52 years (range, 0.04–13.47 years) in the OH group
(P = .81). In the LH group the intended operation was bilateral in 18 (17.4%); 85 were clinically unilateral, but
at operation a contralateral patent processus vaginalis was repaired in 26 (30.5%). Median operative time was
50.5 minutes (range, 20–95 minutes) in the LH group and 20 minutes (range, 10–90 minutes) in the OH cohort
(P < .0001). Recurrence rate was 2.9% in the LH group and 3.9% in the OH group, and overall complication
rates were 7.8% and 9.9%, respectively.
Conclusions: LH repair yields similar results to OH repair; however, the operation time is significantly longer.
All complication rates were statistically similar on balance. Almost one-third of LH procedures resulted in
concurrent detection and repair of a contralateral patent processus vaginalis at laparoscopy.

Introduction repair from January 2010 to December 2013 versus a historic

cohort of all open hernia (OH) repairs between January 2010

T he first laparoscopic repair of an indirect hernia was

reported in an animal model by Ger et al.1 in 1990. Al-
most a quarter of a century later the technique has gone
through many evolutions, including single-port surgery2 and
percutaneous methods,3 and has been widely adopted in adult
practice. Its introduction into pediatric practice, however, has
been somewhat more controversial.4–9 The main concerns
relate to reports of higher recurrence rates,10 longer operating
times, and the debatable natural history of an open contra-
lateral internal ring in an infant or child at laparoscopy.11 The
aim of our study was to compare the surgical outcomes fol-
lowing the introduction of a simple purse string laparoscopic
technique in a tertiary referral center for pediatric surgery.
Materials and Methods
Following institutional ethical approval, a retrospective
review of all children undergoing laparoscopic hernia (LH)
and December 2011 was conducted. The type of operation
selected was purely by individual surgeons’ preference, with
the senior author performing all elective hernia repairs by LH
repair and other members of the department reserving the
technique for incarcerated or recurrent hernias. There was no
patient and/or family preference; all patients presenting un-
derwent the ‘‘randomly allocated’’ surgeon’s preferred ap-
proach. Our service’s age range includes preterm infants up
to children 16 years of age, with no age limits on either
approach. Only 2 patients were excluded from the study (both
unstable premature neonates who had an open repair under
spinal anesthesia). Hydroceles were considered a separate
diagnostic entity and were not performed laparoscopically
and therefore were not part of this study.
LH repair was performed by a simple purse string tech-
nique. In brief, an infraumbilical incision was made, a 5-mm
port was inserted via a direct cut-down, and pneumoper-
itoneum was established to 5–10 mm Hg CO2 insufflation.

Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom.

1
2 STEVEN ET AL.
FIG. 1. Laparoscopic view of the simple purse string repair.
Two further stab incisions were used for direct insertion of 3-
mm or 5-mm instruments. Inspection of the contralateral ring
was performed to decide on the need for contralateral closure.
We defined a significant open contralateral ring as one
through which the camera could be passed into the groin or
one through which viscera could go through, or there was
already obvious herniation. A purse string closure at the in-
ternal ring (avoiding the vas and vessels by picking up the
peritoneum on either side of these structures and between
them) was performed using 3/0 polyethylene terephthalate
(Ethibond; Ethicon, Somerville, NJ) suture (Fig. 1).
Standard OH repair was performed via a groin crease in-
cision through an external oblique window. The sac was
dissected free of the vas and vessels up to the internal ring,
transfixed with 3/0 polyglactin 910 (Vicryl; Ethicon), and
then divided.
Routine outpatient review was offered to patients after
laparoscopic surgery at 3 months and then 1 year as it was
initially a change in practice. Routine outpatient review
was not offered after open surgery except in cases with in-
traoperative difficulty or in the preterm infants. Due to the
regional service we provide, all patients with complications
were seen back in outpatients, and these complications were
captured on review.
Patient demographics were collected, and outcomes were
compared, including operation time, length of stay, and com-
plication rate. Groups were compared using the independent
Table 1. Incidence of Complications Between the Laparoscopic and Open Repair Groups
Complication Laparoscopic (n = 103)
Wound infection 1 (0.97%)
Recurrence 3 (2.9%)
Metachronous hernia 1 (1.2%) (n = 85)
Testicular atrophy 0 1 (0.7%)
Testicular ascent 0 2 (1.3%)
Port-site hernia 3 (2.9%)
Overall 8 (7.8%)
CI, confidence interval; NA, not applicable.
t test or the Mann–Whitney test as appropriate with a P value of
< .05 deemed significant. The 95% confidence intervals are
given.
Results
One hundred three patients (23 females, 80 males) un-
derwent LH repair over the 4-year period compared with 151
(25 females, 126 males) OH repairs in the first 2 years.
Median age in the LH group was 0.56 years (range, 0.04–14.7
years) compared with 0.52 years (range, 0.04–13.47 years) in
the OH group (P = .81). The median weight in the LH group
was 7.8 kg (range, 2–58.2 kg) compared with 7.6 kg (range,
2.06–48.4 years) in the OH group (P = .84). The median
gestation in both groups was 35 weeks (range, 24–42 weeks).
In the OH group there were 8 bilateral hernias and 143 uni-
lateral, of which 3 had contralateral explorations. In the LH
group the intended operation was bilateral in 18 (17.4%), and
85 were clinically unilateral, but at operation a contralateral
patent processus vaginalis (PPV) was repaired in 26 (i.e.,
30.5%). The median operative time was 50.5 minutes (range,
20–95 minutes) in the LH group and 20 minutes (range, 10–
90 minutes) in the OH cohort (P < .0001). In unilateral cases
the operative time in the open group was 25 minutes (range,
10–90 minutes) compared with 45 minutes (range, 20–95
minutes) in the laparoscopic group (P < .001). For bilateral
repair the median operative time in the open group was 35
minutes (range, 20–70 minutes) compared with 64 (range,
27–90 minutes) in the laparoscopic group (P < .001). The
number of trainee-led operations in the LH group was 42%
compared with 80.1% in the OH group. No intraoperative
complications were encountered during LH repair, and the
procedure was well tolerated. Same-day discharge was pos-
sible in 56% who had LH repair and in 33% who had OH
repair (P = .0002).
The median outpatient follow-up was 3 months in both
groups but with a range up to 31.9 months in the LH group
and 1 year in the OH group. In the LH group 16 patients had
incomplete follow-up data as they were seen in peripheral
outreach centers, and these clinic letters were not able to be
reviewed; 5 patients were lost to follow-up as they failed to
attend. The median follow-up period since the date of surgery
until the current review was 3.86 years for both groups, and
this is probably more representative as a follow-up time pe-
riod given the catchment area and referral demographics (i.e.,
we have a relatively stable and nonmigratory population, and
as such all complications and recurrences would come back
to our single center). The comparative postoperative com-
plications are shown in Table 1. The recurrences in the LH
Open (n = 151) P value (95% CIs)
0 .32 (-0.009 to 0.02)
6 (3.9%) .65 (-0.05 to 0.03)
6 (4.3%) (n = 132) .15 (-0.07 to 0.01)
.31 (-0.006 to 0.01)
.16 (-0.05 to 0.03)
NA NA
15 (9.9%) .56 (-0.09 to 0.05)
SIMPLE PURSE STRING LAPAROSCOPIC HERNIA REPAIR
group occurred at 1 day and 5 months after repair. In the OH
group they occurred at a mean of 197 days (range, 1–448
days) after repair. All laparoscopic repairs were redone la-
paroscopically. The findings at redo surgery were an open
ring with the suture embedded in the tissues (presumed knot
failure) in 2 cases and no visible suture in 1 patient in whom
Vicryl was inadvertently used for closure. All except 2 cases
of recurrent open hernia were managed by redo open surgery.
The other 2 cases were redone laparoscopically. Overall there
was no significant difference in postoperative outcome in
terms of complications between the two groups.
Discussion
A recent randomized controlled trial published by the
Helsinki group12 aimed to answer the main controversies
surrounding the debate of whether LH repair in children is a
suitable alternative to traditional groin exploration and her-
niotomy. The trial concluded that the two procedures were
similar in terms of surgical and cosmetic result but that lap-
aroscopic repair involved longer operative time and an in-
creased incidence of postoperative pain. The results of our
series support the longer operative time, and in fact our me-
dian time of 50.5 minutes (range, 20–95 minutes) is longer
than that reported by others—33 minutes by Koivusalo et al.12
and 23 minutes by Chan et al.13—but this is most likely a
reflection that a considerable number of LH procedures are
performed by trainees learning the technique (40.7%).
Also, the exact operative time quoted in different articles
varies; our operative time includes anesthetic time and is not
‘‘knife to skin’’ time and is therefore not accurate. There was
no prospective aim to document operative times in either
group, and therefore operative times are not accurate. In a
retrospective review of the anesthetic charts only approxi-
mate overall operative time could be discerned.
It is also important to highlight that one-third of the patients
explored for clinically unilateral hernias had a contralateral
PPV repaired, and so allowing for this large number of bi-
lateral operations, in fact the median operative time is similar
to that in the literature.
In addition, despite longer operating times the majority of
patients are discharged as day cases. This suggests that we do
not have the same experience of increased postoperative pain,
although we have not analyzed that specifically in our series.
It would also be prudent to state that not all patients are
treated with the intention of same-day discharge. Many pa-
tients with prematurity or associated morbidities are routinely
kept overnight; therefore the individual patient demographics
more often may determine the hospital stay. As this study is
not randomized these confounding factors do no equate be-
tween groups.
It has long been debated among pediatric surgeons as to
whether to perform contralateral groin exploration when
faced with a clinical unilateral hernia.14 LH repair allows the
surgeon to clearly visualize the contralateral internal ring and
to assess its patency laparoscopically. Hall et al.15 tried to
quantify this statistically and concluded that the probability
of a contralateral PPV in an 8 month old was 50% (number
needed to explore = 2), and it fell to 33% in a 4 year old
(number needed to explore = 3) and to 25% (number needed
to explore = 4) by 6 years of age. In our series one-third of the
children were found to have an open contralateral internal
3
ring; all were repaired with the same purse string method as
for the clinically detected hernia. The reasoning for repairing
these was based on the balance of risk and cost of developing
a contralateral hernia and complications thereof against the
risk of damage to cord structures during contralateral closure.
The excellent visualization of the vas and vessels afforded by
laparoscopy, along with the no touch technique of closure,
minimizes the risk of cord damage. This is somewhat re-
inforced by our findings of no instances of testicular ascent
and testicular atrophy in LH patients.
The debate still continues as to how many of these PPV
cases would go on to develop a clinical hernia and how this
varies with the age of the child. In the OH group there was an
incidence of metachronous hernia of 4.3%. Interestingly, we
found 1 patient in the LH group who developed a meta-
chronous hernia. This was a 45-day-old term baby who had a
right-sided hernia repaired and was thought to have a closed
ring at the original laparoscopy. The rates of recurrence with
LH vary in the literature from 1.13% to 3.1%.12–15 Our re-
currence rate of 2.9% is in keeping with that found in the
literature. The recurrence rate was higher (3.9%) in the cohort
that had an open repair. This difference was not significant.
Ein et al.16 reported a recurrence rate of 1.2% incidence in
6361 infants and children; however, this reflects a personal
series of repairs by a senior consultant. Conversely our series
(both open and laparoscopic) included operations performed
by trainees of all grades and could therefore be more repre-
sentative of the overall outcome in the usual setting where
operations performed under training and service provision.
There are different techniques reported in the literature to
perform LH repair in children. These vary from combined
percutaneous and endoscopic approaches such as the subcu-
taneous endoscopically assisted ligation or SEAL technique,17
incising the hernia sac,18 or purposeful traumatization of the
internal ring to techniques to dissect the PPV from the un-
derlying tissues with an injection technique.19
Here we have shown that a simple purse string technique
with a nonabsorbable braided suture is associated with a low
risk of recurrence and injury. One patient had a recurrence
after the use of Vicryl suture, and of note is that a recent animal
study has shown a higher risk of recurrence in a rabbit model
of pediatric inguinal hernia when absorbable nonbraided su-
tures are used.20 Our experience would therefore reiterate the
use of nonabsorbable suture in laparoscopic cases, as this
combination of laparoscopic approach and nonabsorbable
suture gives the same outcome as open repair. Due to the
different surgical approach of a simple purse string closure
without herniotomy (as is the case with the open procedure),
the use of a nonabsorbable suture may allow for closure and
success without the concomitant herniotomy in this situation.
The occurrence of port-site hernia was an unexpected oc-
currence in 3 patients early in the series. This was despite
direct closure of the sites. There has been none in the latter part
of the series.
There are possible flaws with the findings of this study,
including selection bias. However, we do not feel selection
bias is a significant issue as patient allocation to surgeon is
random, and as such so is the allocation to the method of
repair. Furthermore, it is also assumed that all complications
would be captured by this retrospective review, as by the
nature of our service most complications would return to us
as we provide the only pediatric service in locoregionally.
4 STEVEN ET AL.
The laparoscopic patients were offered routine follow-up to
1 year as this was a relatively new practice, and we were
aiming to accurately determine postoperative complications
in this group of patients. Therefore the complications in this
group are a prospective collection of complications, and
there were no obvious reasons why any complications should
not have been collected. It is fair to assume that patients in
the OH group will have presented with complications if they
occurred.
In conclusion, there are various minimally invasive sur-
gical approaches to pediatric inguinal hernia, and we suggest
that LH repair performed as a simple purse string closure
technique is one that can be effective and associated with a
low complication rate and should be considered at least part
of the pediatric surgeon’s armamentarium. We have shown
that the simple purse string method of LH repair yields
similar results to OH repair in our series; however, the op-
eration time maybe longer. All complication rates were sta-
tistically similar on balance.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Merrill McHoney, MBBS, FRCS (Paed Surg), PhD
Department of Paediatric Surgery
Royal Hospital for Sick Children
Sciennes Road
Edinburgh, EH9 1LF
Scotland, United Kingdom
E-mail: merrillmchoney@nhs.net