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American Journal of Translational Research logoLink to American Journal of Translational Research
. 2024 Oct 15;16(10):5155–5167. doi: 10.62347/VGGJ1398

Clinical efficacy of laparoscopic treatment of pediatric inguinal hernia: a meta-analysis

Huan Luo 1, Jianting Xu 1, Jiahao Chen 1, Zhenchao Ni 1
PMCID: PMC11558404  PMID: 39544795

Abstract

Objective: To evaluate operative outcomes and postoperative complications of laparoscopic treatment for pediatric inguinal hernia using meta-analysis. Methods: We conducted a comprehensive search of databases including the Chinese Journal Full-text Database, Wanfang, PubMed, Web of Science, ScienceDirect, VIP Chinese Science, and Technology Journal Database, ProQuest, JSTOR, Wiley, and IEEE Xplore. Relevant randomized controlled trials (RCTs) on laparoscopic surgery for pediatric inguinal hernia were collected, and data were analyzed using Review Manager 5.3. Results: A total of 18 RCTs involving 5,750 children (3,357 in the laparoscopic group and 2,393 in the open surgery group) were included. Compared to the open surgery group, the laparoscopic group had significantly shorter operative times for bilateral hernias [(mean difference (MD) = -11.43, P = 0.04)], and lower incidences of metachronous contralateral inguinal hernia (MCIH) (MD = 0.17, P = 0.02) and testicular ascent (MD = 0.19, P = 0.03). However, there were no significant differences in operative time for unilateral hernia (MD = 0.47, P = 0.87), complication rate (MD = 0.87, P = 0.60), postoperative recurrence (MD = 1.46, P = 0.18), incision infection rate (MD = 2.54, P = 0.34), or testicular atrophy rate (MD = 0.36, P = 0.19). Conclusion: Laparoscopic surgery for pediatric inguinal hernia is effective, especially for bilateral cases, reducing operative time and lowering the risk of MCIH and testicular ascent.

Keywords: Laparoscopic, hernia, inguinal, open operation, child, meta

Introduction

The inguinal region is the triangular area at the junction of the lower abdominal wall and the thigh. An inguinal hernia occurs when internal organs protrude through a defect in the inguinal area, commonly referred to as a “hernia” [1]. This condition is frequently seen in pediatric surgery, with an incidence ranging from 0.8% to 4.4% [2]. The primary pathologic cause is a congenital failure of the vaginalis process to close, with increased intra-abdominal pressure acting as a triggering factor [3,4].

Currently, most researchers agree that as children grow, the abdominal wall muscles, aponeurosis, and other tissues continue to strengthen. Therefore, simple high ligation of the hernia sac remains the standard treatment for pediatric inguinal hernia [5]. However, open surgery, which involves dissecting the inguinal canal and freeing the spermatic cord and hernia sac, carries risks such as spermatic vessel injury, testicular atrophy, and iatrogenic cryptorchidism. Besides, this method has several disadvantages, including high trauma, scarring, and a prolonged recovery time [6].

In recent years, advancements in technology, and in minimally invasive surgery have led to the widespread adoption of laparoscopic techniques in pediatric inguinal hernia repair. Laparoscopic surgery offers advantages such as minimal invasiveness, faster recovery, lower recurrence rate, and improved cosmetic outcome [7,8]. However, the clinical efficacy, surgical outcome, recurrence rate, and complications associated with laparoscopic surgery in children remain debated. Currently, there is insufficient high-quality, large-scale clinical data to validate conclusively its benefits through evidence-based medicine.

Meta-analysis, a statistical method for quantitatively synthesizing independent research results, can provide comprehensive evidence for these surgical comparisons [9]. Therefore, we conducted a meta-analysis to compare surgical outcomes, recurrence rates, and postoperative complications between laparoscopic and traditional open surgery for pediatric inguinal hernia, aiming to provide stronger evidence-based guidance for clinical decision-making.

Materials and methods

PROSPERO statement

This study has been registered with PROSPERO (CRD42024578885).

Retrieval tool

We systematically searched multiple databases, including the Chinese Journal Full-text Database, VIP Chinese Science and Technology Journal Database, ProQuest, Wanfang, PubMed, JSTOR, Web of Science, ScienceDirect, Wiley, and IEEE Xplore, to collect randomized controlled trials (RCTs) comparing laparoscopic and traditional open surgery for pediatric inguinal hernia. The search covered studies from database inception to February 31, 2024. English search terms included “children”, “inguinal hernia”, “groin hernia”, “direct inguinal”, “laparoscope”, “laparoscopic surgery”, “open surgery”, and “traditional surgery”, connected with “OR” or “AND” as appropriate. We also manually searched the reference lists of included studies.

English subject terms included “laparoscopic”, “open operation”, “infantile inguinal hernia”, and “child”. Free terms included “efficacy”, “operative time bilateral”, “MCIH”, “testis ascending”, “operative time unilateral”, “complication”, “postoperative recurrence”, “incision infection”, “testis atrophy”, “RCT”, and “randomized controlled trial”. We adjusted the search strategy based on the specific database and used a combination of subject and free terms. The detailed search strategy is as follows: (((((((((((((((laparoscopic[Title/Abstract]) AND (open operation[Title/Abstract])) AND (infantile inguinal hernia[Title/Abstract])) AND (child[Title/Abstract])) AND (efficacy[Title/Abstract])) OR (operative time bilateral[Title/Abstract])) OR (MCIH[Title/Abstract])) OR (metachronous contralateral inguinal hernia[Title/Abstract])) OR (testis ascending[Title/Abstract])) OR (operative time unilateral[Title/Abstract])) OR (complication[Title/Abstract])) OR (postoperative recurrence[Title/Abstract])) OR (incision infection[Title/Abstract])) OR (testis atrophy[Title/Abstract])) OR (RCT[Title/Abstract])) OR (randomized controlled trial[Title/Abstract]).

Inclusion criteria

Studies were included if they met the following criteria: (1) RCT design; (2) Subjects were children; (3) Clear diagnosis of inguinal hernia [10]; (4) Comparison of laparoscopic surgery with open surgery; (5) Clear outcome indicators; (6) Complete data and published in English.

Exclusion criteria

Studies were excluded if they met any of the following: (1) Subjects had hydrocele, testicular insufficiency, testicular mass, history of abdominal or groin surgery, recurrent hernia; (2) Reviews, case reports, clinical guidelines, or conference abstracts; (3) Poor study design, lack of clear results, or unclear data reporting; (4) Incomplete data or logical errors; (5) Duplicate publications.

RCT bias risk assessment

The risk of bias in included RCTs was assessed using the Cochrane tool [11]. This tool evaluates several types of bias: selection, performance, detection, attrition, and reporting bias. Two independent researchers conducted the assessment, and any disagreements were resolved through discussion or consultation with a third party.

Literature screening and data extraction

We systematically searched databases to identify literature related to the clinical efficacy of laparoscopic treatment for pediatric inguinal hernia. We reviewed abstracts and keywords, selecting studies based on predefined inclusion and exclusion criteria. The extracted data included the first author, publication year, number of cases (laparoscopy/open group), age, sex, follow-up duration, outcome measures, and measured data. This process was conducted independently by two researchers using standardized protocols. After extraction, discrepancies were resolved through discussion or by consulting a third researcher.

Outcome measures included operative time, recurrence rate, complication rate, incision infection rate, MCIH incidence, testicular atrophy rate, and testicular ascent rate. Recurrence was defined as the reappearance of a bulge at or near the site of the previous repair, confirmed by ultrasound as containing a loop of intestine [12]. Operative time was measured from anesthesia induction to wound closure, including unilateral and bilateral cases [13]. MCIH refers to the development of a contralateral hernia after previous inguinal hernia surgery [14].

Statistical analysis

Meta-analysis was conducted using Review Manager 5.3. The Cochrane Q test and I2 statistic were used to assess heterogeneity among studies. The Z-test was applied to further analyze inter-study variability. If heterogeneity was absent (P > 0.1, I2 < 50%), a fixed-effects model (FEM) was employed. In cases of significant heterogeneity, a random-effects model (REM) was adopted. The I2 statistic quantifies variability between studies, with I2 = 0 indicating that all variability is due to sampling error. I2 values between 0.25 and 0.5 indicate moderate heterogeneity, while values above 0.5 suggest high heterogeneity.

Mean difference (MD) and relative risk (RR) were used as effect measures for continuous and categorical data, respectively, with 95% confidence intervals (CI) provided. A funnel plot was generated to evaluate publication bias, and sensitivity analysis was performed by comparing FEM and REM results. The Begg rank correlation test and Egger’s linear regression method were used in STATA 15.0 to detect publication bias. Evidence quality was graded using GRADEpro 3.6.

Results

Literature screening process

We initially identified 4,136 studies, and after a rigorous screening process, 18 studies were included in the meta-analysis [15-32]. These studies comprised 3,357 laparoscopic and 2,393 open surgical procedures (Figure 1).

Figure 1.

Figure 1

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Literature screening and elimination flow chart.

Data from the 18 studies

Complete information was obtained from all 18 studies (Table 1). Overall, the studies were of high quality with minimal impact on the strength of evidence in the meta-analysis. Low bias risk in random sequence generation (selection bias), allocation concealment (selection bias), participant and personnel blinding (performance bias), outcome assessment blinding (detection bias), incomplete outcome data (attrition bias), and selective reporting (reporting bias) have been demonstrated. Other studies showed some uncertainty in the degree of bias risk (Figure 2).

Table 1.

Information from 18 studies included

First author and year Surgery Cases Age (months) Gender (Male/female) Follow-up time Outcome indicator
Celebi S 2014 [15] Laparoscopy 30 8.24±2.60 - 3 months after surgery ① ③
Open 32 7.83±1.58 -
Koivusalo AI 2009 [16] Laparoscopy 47 6.00 (36/11) 2 years after surgery ① ② ③
Open 42 6.10 (30/12)
Saranga Bharathi R 2008 [17] Laparoscopy 35 5.58±3.52 (30/5) 3.5 months (mean) ① ② ③
Open 34 3.14±0.92 (32/2)
Chan KL 2005 [18] Laparoscopy 41 4.67±3.81 (34/7) 12.21±2.83 ① ② ③
Open 42 3.83±2.85 (33/9) 11.79±2.54
Shalaby R 2012 [19] Laparoscopy 125 58 1-12 months, 45 12-24 months, 22 > 24 months (38/87) 24 months (mean) ② ③ ④ ⑥ ⑦
Open 125 50 1-12 months, 55 12-24 months, 20 > 24 months (92/33)
Timberlake MD 2015 [20] Laparoscopy 38 21.5 months (median) (34/4) 51 days (median) ②
Open 38 23 months (median) (36/2) 47 days (median)
Nah SA 2011 [21] Laparoscopy 28 5.39±4.11 (23/5) 3 months (median) ② ③ ⑥ ⑦
Open 35 3.1 months (median) (31/4) 4 weeks - 3 years
Mishra PK 2014 [22] Laparoscopy 27 NR (24/3) 4 weeks - 3 years ② ③ ④ ⑤ ⑥
Open 45 NR (40/5) 4 weeks - 2 years
Lin CD 2011 [23] Laparoscopy 24 7.17±4.21 (20/4) 22.9±10.5 months ① ②
Open 31 5.39±4.11 (25/6) 20.2±10.5 months
Koivusalo A 2007 [24] Laparoscopy 18 5.1 months (median) (17/1) 26 months (median) ②
Open 15 9.1 months (median) (14/1)
Jun Z 2016 [25] Laparoscopy 84 1.8 years (median) (48/36) 3-9 month ②
Open 42 2 years (median) (20/22)
Hassan ME 2007 [26] Laparoscopy 15 39 months (median) (15/0) 3 months ②
Open 18 44 months (median) (18/0)
Endo M 2009 [27] Laparoscopy 1257 3.7±3.2 (694/563) 1-11 years ① ②
Open 308 3.8±2.9 (226/82)
Amano H 2017 [28] Laparoscopy 1033 49.0±36.2 (488/545) 29.1±24.3 months ② ④ ⑤ ⑦
Open 995 48.8±36.0 (632/363) 49.3±50.5 months
Ahmed A 2022 [29] Laparoscopy 148 4.58±2.97 (133/15) 6 months after surgery ① ②
Open 148 4.96±3.13 (133/15)
Kara YA 2021 [30] Laparoscopy 227 4.56±3.74 (144/83) 30.4 months ① ② ③
Open 178 4.19±3.34 (123/55) 24.4 months (mean)
Ergün E 2021 [31] Laparoscopy 85 (73/12) 12 months after the surgery ① ②
Open 55 (44/11)
Suttiwongsing A 2022 [32] Laparoscopy 95 3 years (median) (62/) 23.7±0.7 months ① ②
Open 210 3 years (median) (146/) 33.1±5.7 months
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Note: Outcome indicator: ① Operation time (min); ② Recurrence rate; ③ Complication rate; ④ Incision infection rate; ⑤ MCIH occurrence rate; ⑥ Testis atrophy rate; ⑦ Testicular ascent rate; NR: not reported.

Figure 2.

Figure 2

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Risk of bias across studies. Note: Kara YA 2021, Shalaby R 2012, and Timberlake MD 2015 demonstrated a higher risk of bias in random sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), and selective reporting (reporting bias). Other studies displayed some degree of uncertainty regarding these risks of bias.

More than 50% of studies had low risk of bias for allocation concealment, participant and personnel blinding, outcome assessment blinding, incomplete outcome data, and selective reporting. Additionally, over 75% of studies demonstrated low risk of performance and detection bias (Figure 3).

Figure 3.

Figure 3

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Risk of bias in 18 studies. Note: Among the included studies, more than 50% had a low risk of bias for allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), and selective reporting (reporting bias). Furthermore, more than 75% of studies showed a low risk of bias in participants and personnel (performance bias) and blinding of outcome assessment (detection bias).

Meta-analysis

Operation time

Ten papers reported the operative time for unilateral hernias. Meta-analysis showed no significant difference in operative time between the groups (MD = 0.47, 95% CI: -4.93-5.86, P = 0.87) (Figure 4A). For bilateral hernias, eight studies were included, and meta-analysis indicated that the laparoscopic group had a shorter operative time (MD = -11.43, 95% CI: -22.20-0.66, P = 0.04) (Figure 4B).

Figure 4.

Figure 4

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Forest map of operation time comparison. Note: (A) Operative Time (min) Unilateral; (B) Operative Time (min) Bilateral.

Complication rate

Eight papers reported complication rates, and meta-analysis revealed no significant difference between the laparoscopic and open surgery groups (MD = 0.87, 95% CI: 0.51-1.46, P = 0.60) (Figure 5).

Figure 5.

Figure 5

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Forest map comparing complication rates.

Postoperative recurrence rate

Seventeen studies provided data on recurrence rates, and meta-analysis showed no significant difference between the groups (MD = 1.46, 95% CI: 0.84-2.52, P = 0.18) (Figure 6).

Figure 6.

Figure 6

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Forest map comparing postoperative recurrence rates.

Incision infection rate

Three studies reported incision infection rates. Meta-analysis showed no significant difference between the groups (MD = 2.54, 95% CI: 0.37-17.36, P = 0.34) (Figure 7).

Figure 7.

Figure 7

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Forest map of incision infection rate comparison.

MCIH occurrence rate

Six studies reported the occurrence of MCIH. The incidence was significantly lower in the laparoscopic group (MD = 0.17, 95% CI: 0.04-0.72, P = 0.02) (Figure 8).

Figure 8.

Figure 8

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Forest map of metachronous contralateral inguinal hernia, occurrence rate.

Testicular atrophy rate

Three studies reported the rate of testicular atrophy, and meta-analysis showed no significant difference between the groups (MD = 0.36, 95% CI: 0.08-1.63, P = 0.19) (Figure 9).

Figure 9.

Figure 9

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Forest map comparing testicular atrophy rates.

Testicular ascent rate

Three studies reported the rate of testicular ascent. Meta-analysis indicated that the testicular ascent rate was significantly lower in the laparoscopic group (MD = 0.19, 95% CI: 0.04-0.84, P = 0.03) (Figure 10).

Figure 10.

Figure 10

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Forest map for comparison of testicular ascent rate.

Publication bias risk assessment and sensitivity analysis

A funnel plot (Figure 11) was used to assess publication bias. For operative time (unilateral and bilateral), there was evidence of publication bias, as some studies intersected with or were outside the funnel plot’s confidence limits. However, no publication bias was found for complication rate or recurrence rate, as the funnel plots showed good symmetry. Due to limited data, publication bias could not be evaluated for incision infection rate, MCIH incidence, testicular atrophy rate, or testicular ascent rate. Sensitivity analysis, conducted by comparing FEM and REM results, showed no significant change in the combined effect sizes for all outcomes except testicular ascent, indicating that the meta-analysis results were robust and reliable.

Figure 11.

Figure 11

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Publication bias assessment. Note: (A) Operative Time Unilateral; (B) Operative Time Bilateral; (C) Complication rate; (D) Postoperative recurrence rate. MD: mean difference; RR: relative risk; SE: standard error.

Among the 10 studies on unilateral operative time, the Begg rank correlation test (P = 0.353) and Egger linear regression method (P = 0.603) indicated no significant publication bias. For bilateral operative time (8 studies), Begg (P = 0.692) and Egger (P = 0.125) also showed no significant publication bias. Similarly, for complication rate (8 studies), the Begg (P = 0.412) and Egger (P = 0.569) tests suggested no significant publication bias. Regarding recurrence rate (17 studies), Begg (P = 0.620) and Egger (P = 0.553) indicated no significant publication bias. The same was true for incision infection rate (Begg: P = 0.559, Egger: P = 0.163), MCIH incidence (Begg: P = 0.713, Egger: P = 0.125), testicular atrophy rate (Begg: P = 0.367, Egger: P = 0.072), and testicular ascent rate (Begg: P = 0.621, Egger: P = 0.103).

GRADE assessment

Using GRADEpro 3.6 software, the quality of evidence for operation time, complication rate, postoperative recurrence rate, incision infection rate, MCIH occurrence rate, testicular atrophy rate, and testicular ascent rate was assessed as very low (Figure 12).

Figure 12.

Figure 12

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GRADE assessment. Note: MCIH: metachronous contralateral inguinal hernia.

Discussion

Inguinal hernia is a common congenital condition in children, with surgery being the definitive treatment. Traditional high ligation of the hernia sac has several limitations, such as visible scarring, inability to simultaneously detect contralateral occult hernias, significant trauma, and a relatively high recurrence rate [33]. Christophersen et al. [34] reported that the recurrence rate after open inguinal hernia repair can be as high as 5%. Therefore, it is crucial to explore other effective surgical methods for pediatric inguinal hernia treatment. Laparoscopic surgery has gained popularity due to its advantages, including minimal trauma, faster recovery, reduced blood loss, and the ability to explore contralateral hernias and visualize local anatomy [35].

Ensuring patient safety during surgery is paramount. Our systematic analysis revealed several benefits of laparoscopic surgery in treating pediatric inguinal hernia, including shorter bilateral operative time, lower rate of MCIH, and reduced testicular ascent. The shorter operative time for bilateral hernias in laparoscopic surgery, compared to open surgery, may be due to the smaller incisions, the use of electrocoagulation, and the lack of need to separate the hernia sac. Additionally, the clearer visual field in laparoscopic procedures helps avoid injury to key structures such as blood vessels and nerves, reducing the need for additional intraoperative maneuvers and shortening the operative time [36]. However, the operative time for unilateral hernias showed no significant advantage performed by laparoscopy, likely because unilateral hernia repairs are less complex and can be performed quickly, regardless of the surgical approach [37]. Pulikkal et al. [38] also demonstrated that the average operative time for unilateral hernia repair was 8 minutes, while bilateral hernia repair took 11 minutes, with similar findings in laparoscopic surgery.

The discrepancy in operative times between different studies could be attributed to individual patient factors and the surgeon’s proficiency with laparoscopic techniques. For instance, in laparoscopic surgery, there is no need to separate the spermatic cord or open the cremaster muscle. However, Zhang et al. [39] found that laparoscopic surgery extended the operative time, which contradicts our findings, possibly due to the surgeons’ varying levels of expertise. Therefore, continuous improvement in laparoscopic technical standards and training programs is essential.

Our quantitative analysis also showed a lower incidence of MCIH following laparoscopic surgery (0.3%) compared to open surgery (3.7%) [40]. MCIH often occurs after unilateral hernia repair, and most experts believe it originates from a contralateral patent processus vaginalis (CPPV), though the exact mechanism is still unclear [41]. Laparoscopic percutaneous high ligation (LPEC) allows for the timely detection and treatment of CPPV on the contralateral side, reducing the risk of postoperative MCIH [42].

Testicular displacement after hernia repair in children may result from factors such as excessive manipulation of the hernia sac, which can lead to damage of the testis, spermatic cord, and surrounding tissues. These injuries may impair blood supply to the testis, slow the development of testicular interstitial cells, and reduce testosterone production. In some cases, surgical trauma can directly damage receptors on target cells, further affecting hormone levels. Obayashi et al. [43] identified birth weight below 932 g and spermatic duct hematoma as risk factors for testicular displacement. The lower risk of testicular ascent following laparoscopic hernia repair may be due to the less invasive nature of the procedure.

Our study confirmed that laparoscopic surgery is an effective and safe treatment for infantile inguinal hernia. As such, we recommend laparoscopic surgery as the first choice, provided economic conditions allow. However, in cases with specific conditions - such as infants younger than six months, patients with inguinal wall defects, or those with incarcerated hernias - traditional open surgery may be more appropriate.

The GRADE system was used to assess the quality of evidence across different outcome measures. Our analysis found that the quality of evidence was “Very Low” for operative time, complication rate, recurrence rate, incision infection rate, MCIH rate, testicular atrophy rate, and testicular ascent rate. This suggests that future studies may alter the conclusions in these areas.

Despite establishing strict inclusion and exclusion criteria and conducting a risk-of-bias assessment, our study has several limitations. Some included studies exhibited high heterogeneity, likely due to differences in patient age, physical characteristics, and surgical complexity. Furthermore, certain outcomes, such as incision infection rate, testicular atrophy rate, and testicular ascent rate, were based on only three studies, limiting the robustness of the findings. Another limitation is that our study did not account for the specific type of laparoscopic technique used, which may influence outcome. Additionally, the relatively small number of included studies made it difficult to conduct subgroup analyses based on age or disease severity.

As a result, while our meta-analysis provides valuable insights, more further research is needed to strengthen the evidence base. Due to these limitations, the conclusions presented here should be interpreted cautiously and considered a reference for clinical decision-making.

In conclusion, based on current evidence, laparoscopic surgery for infantile inguinal hernia is effective, especially for bilateral cases, where it shortens operative time and reduces the risk of MCIH and testicular displacement. However, this evidence does not definitively establish that laparoscopic surgery is safer than open surgery.

Disclosure of conflict of interest

None.

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