Abstract
Background:
Laparoscopic inguinal hernia repair (IHR) has become increasingly popular in children, particularly in infants <6 months old, despite limited data on technical variations and outcomes relative to open IHR. This multicenter retrospective study examined how rates of subsequent inguinal hernias in infants were affected by cauterizing the internal ring and using permanent suture during laparoscopic IHR. We also assessed the impact of performing diagnostic laparoscopy during open IHR.
Methods:
Patients <6 months old who underwent primary IHR between 1/1/2018 and 12/31/2019 were identified at 14 children’s hospitals within a regional clinical research consortium. Information was collected regarding patient demographics, operative technique, and incidence of subsequent inguinal hernia (recurrent ipsilateral and metachronous contralateral inguinal hernia).
Results:
Among 1532 infants identified, 1016 (66.3 %) underwent open IHR and 516 (33.7 %) underwent laparoscopic IHR. Median time from primary IHR to data entry was 6 years. Performing ring cauterization and using permanent suture during laparoscopic IHR was associated with a significantly lower incidence of recurrent ipsilateral hernia (0.5 % versus. 6.2 %, p < 0.01 ), comparable to the recurrence rate after open IHR (0.5 % versus 1.2 %, p = 0.40). Similarly, diagnostic laparoscopy during open IHR was associated with a significantly lower incidence of metachronous contralateral hernia (1.4 % versus 3.8 X, p = 0.03), comparable to the rate seen after laparoscopic IHR (1.4 % versus 1.2 %, p = 0.79).
Conclusion:
In infants <6 months old undergoing primary IHR, rates of subsequent inguinal hernias can be significantly reduced by cauterizing the internal ring and using permanent suture during laparoscopic IHR and by performing diagnostic laparoscopy during open IHR.
Keywords: Laparoscopic inguinal hernia repair, Open inguinal hernia repair, Recurrent ipsilateral hernia, Metachronous contralateral hernia, Infants
1. Introduction
Over the past 15 years, there has been a significant increase in the percentage of pediatric inguinal hernia repairs (IHRs) performed laparoscopically in the United States (US). This trend has been most pronounced in patients 0—6 months old, for whom approximately 45 % of IHRs were performed laparoscopically in 2022—nearly double the rate of laparoscopic IHR in any other pediatric age group—according to data from the Pediatric Health Information System (PHIS) [1,2]. In a recent regional survey of pediatric surgeons at tertiary children’s hospitals, over 90 % of early-career respondents reported a preference for laparoscopic over open IHR in infants, suggesting that rates of laparoscopic IHR in this patient population will continue to rise rapidly [3]. However, this notable shift in the management of inguinal hernias in infants is occurring without robust data to support the durability of the laparoscopic approach or to guide optimal surgical techniques [4].
Laparoscopic IHR is feasible and safe in children [5–10], but few studies have focused on outcomes in infants [11–16]. It may be important to consider each pediatric age group independently when measuring outcomes after IHR. As anatomy evolves during childhood, so too does the shape and trajectory of the inguinal canal and the presumed forces to which an inguinal hernia repair is subjected. Prior studies comparing outcomes after laparoscopic and open IHR in infants have generally concluded that the overall rate of subsequent hernias (defined as either a recurrent ipsilateral or a metachronous contralateral hernia) is similar between techniques, but open IHR results in higher rates of metachronous contralateral hernias, and laparoscopic IHR results in higher rates of recurrent ipsilateral hernias [17–21], However, data in infants have been limited by small sample sizes, short duration of follow-up, and failure to account for potentially meaningful technical variations [11–16].
While all types of IHR in young children involve closing the internal ring, there are technical considerations during both laparoscopic and open IHR that might influence outcomes. On the basis of small animal studies and clinical experience, several groups have advocated for cauterization of the internal ring and the use of permanent suture around the ring to reduce the likelihood of recurrent ipsilateral hernia after laparoscopic IHR [7,22–24], Recent evidence indicates that the majority of pediatric surgeons perform ring cauterization and use permanent suture during laparoscopic IHR, but no large clinical study has evaluated the impact of these techniques on ipsilateral recurrence rates [3,25], During open IHR, use of diagnostic laparoscopy to visualize the contralateral processus vaginalis is thought to reduce rates of metachronous contralateral hernia, but this effect has not been measured specifically in infants [26,27],
The purpose of this multicenter retrospective study was to compare rates of subsequent inguinal hernias after primary open and laparoscopic IHR in infants 0—6 months old, with attention to specific technical variations during both approaches. We hypothesized that (1) open and laparoscopic IHR would have comparable overall rates of subsequent inguinal hernias, (2) cauterization of the internal ring and use of permanent suture during laparoscopic IHR would reduce rates of recurrent ipsilateral hernias, and (3) diagnostic laparoscopy during open IHR would reduce rates of metachronous contralateral hernias.
2. Methods
2.1. Study design and eligibility criteria
Institutional review board approval was obtained from 14 member children’s hospitals within the Eastern Pediatric Surgery Network (EPSN). We conducted a retrospective cohort study that included all infants who underwent IHR at less than 6 months old between 1/1/2018 and 12/31/2019. Cases were identified at each center based on review of all IHRs queried in the electronic medical record by Current Procedural Terminology codes (Supplementary Table 1). Patients were excluded if they had a history of IHR prior to the designated study period.
2.2. Data collection
Charts were reviewed for patient demographics, operative technique during primary IHR, and incidence of subsequent inguinal hernias postoperatively. Operative details included surgical approach (open versus laparoscopic IHR), specific technique used to close the internal ring during laparoscopic IHR (percutaneous suture placement, intracorporeal suture placement, or sac inversion), intentional cauterization of the internal ring during laparoscopic IHR, diagnostic laparoscopy during open IHR, and type of suture used to close the internal ring (permanent versus absorbable). Patients with missing data regarding preoperative diagnosis and/or operative details were excluded from statistical models that included those variables. All data were collected and managed using REDCap (Research Electronic Data Capture) tools [28] hosted at Yale University.
2.3. Statistical analysis
The primary outcome was any subsequent inguinal hernia documented in the chart following index IHR, including recurrent ipsilateral hernias and metachronous contralateral hernias. Follow-up was calculated as the time interval between primary IHR and date of data entry into REDCap, although we could not verify that patients remained in the same hospital system during this interval. Patients who developed subsequent bilateral hernias following primary unilateral IHR were considered to have both recurrent ipsilateral and metachronous contralateral hernias. Specific comparisons included: (1) rate of subsequent inguinal hernias after all open IHR versus all laparoscopic IHR; (2) rate of recurrent ipsilateral hernias after (a) all open IHR versus all laparoscopic IHR, (b) open IHR with permanent suture versus absorbable suture, (c) laparoscopic IHR with permanent suture versus absorbable suture, cauterization of the internal ring versus no cauterization, and different laparoscopic approaches (percutaneous versus intracorporeal versus sac inversion); (3) rate of metachronous contralateral hernias after (a) all laparoscopic IHR versus all open IHR, and (b) open IHR with diagnostic laparoscopy versus without diagnostic laparoscopy. We also compared hospital-level variables between participating centers, including overall distribution of laparoscopic and open IHRs during the study interval, frequency of ring cauterization and permanent suture placement during laparoscopic IHR, frequency of diagnostic laparoscopy during open IHR, and rates of subsequent hernias. Statistical analysis was performed using Stata/MP 18.0 (College Station, TX). Independent sample t-tests were used to compare means of continuous variables, and Fisher’s exact and Chi-square tests were used for categorical variables. Data were presented as mean ± standard deviation unless indicated otherwise. An a priori alpha level was set at 0.05.
3. Results
3.1. Study population and patient demographics
There were 1532 patients between 0 and 6 months of age who underwent primary IHR during the study interval, including 1016 (66.3 %) who underwent open IHR and 516 (33.7 %) who underwent laparoscopic IHR. There were no significant differences between the open and laparoscopic groups with respect to sex, gestational age or birth weight, corrected gestational age or weight at time of primary IHR, percentage of patients with a history of prematurity, or percentage of patients requiring supplemental oxygen at time of IHR. Patients who underwent open IHR were significantly more likely to have a history of prior abdominal surgery and have a preoperative diagnosis of bilateral hernia (Table 1).
Table 1.
Patient demographics.
| Total (n = 1532) | Open (n = 1016) | Laparoscopic (n = 516) | P-value | |
|---|---|---|---|---|
| Female (%) | 28 (18.7%) | 201 (19.8%) | 86 (16.7%) | 0.15 |
| Gestational age at birth, weeks (IQR) | 34 (29–38) | 34 (29–38) | 34 (29–38) | 0.63 |
| Premature (%) | 881 (58.8 %) | 583 (58.8 %) | 298 (58.7%) | 0.96 |
| Age at primary IHR, weeks (IQR) | 12 (8–16) | 12 (8–17) | 12 (8–16) | 0.54 |
| Corrected gestational age at primary IHR, weeks (IQR) | 46 (42–49) | 46 (42–49) | 46 (42–49) | 0.36 |
| Birthweight, kilograms (IQR) | 1.8 (1.0–2.8) | 1.7 (1.0–2.8) | 1.8 (1.0–2.8) | 0.96 |
| Weight at primary IHR, kilograms (IQR) | 4.5 (3.5–5.5) | 4.4 (3.5–5.4) | 4.5 (3.5–5.6) | 0.36 |
| History of necrotizing enterocolitis | 48 (3.2 %) | 33 (3.3 %) | 15 (2.9 %) | 0.76 |
| History of abdominal surgery prior to IHR | 66 (4.3 %) | 52 (5.1 %) | 14 (2.7 %) | 0.032 |
| Preoperative diagnosis of bilateral hernia | 320 (20.9%) | 230 (22.6 %) | 90 (17.4%) | 0.020 |
| Baseline supplemental oxygen support at primary IHR | 110 (7.2 %) | 73 (7.2 %) | 37 (7.2 %) | 1.00 |
3.2. Outcomes following open and laparoscopic IHR
Median time interval between primary IHR and date of entry into the study database was 6.0 years (IQR 5.6—6.6 years, minimum 4.7 years). There were 57 patients (3.7 %) who developed subsequent inguinal hernias, including 30 with recurrent ipsilateral hernias, 24 with metachronous contralateral hernias, and 3 with both recurrent ipsilateral hernia and metachronous contralateral hernias. The overall rate of subsequent inguinal hernias was 4.8 % after laparoscopic IHR and 3.2 % after open IHR (p = 0.10; Fig. 1). The rate of recurrent ipsilateral hernias was 4.1 % after laparoscopic IHR versus 1.2 % after open IHR (p < 0.01 ; Fig. 1 ). In patients with a preoperative diagnosis of unilateral hernia, the rate of metachronous contralateral hernias was 2.7 % after open IHR versus 1.2 % after laparoscopic IHR (p = 0.09; Fig. 1).
Fig. 1. Rates of subsequent inguinal hernias.
Although there was no significant difference in overall rate of subsequent inguinal hernias between open and laparoscopic IHR, there was a significantly higher rate of recurrent ipsilateral hernias after laparoscopic IHR and a trend toward higher rate of metachronous contralateral hernias after open IHR.
3.3. Impact of technique on outcomes following laparoscopic IHR
Among patients undergoing laparoscopic IHR, 475 (92.1 %) underwent percutaneous repair, 19 (3.7 %) underwent intracorporéal repair, 12 (2.3 %) underwent sac inversion, and 10 (1.9 %) had incomplete data regarding operative approach. There was no significant difference in rates of recurrent ipsilateral hernias when comparing percutaneous (3.4 %, 16/475) to intracorporéal (10.5 %, 2/19; p = 0.15) or sac inversion (16.7 %, 2/12; p = 0.07) techniques. Cauterization of the internal ring was performed in 41.5 % (214/516) of laparoscopic IHRs, and permanent suture was used to close the internal ring in 90.3 % (466/516) of laparoscopic IHRs. There were no significant differences between male and female patients in rates of internal ring cauterization (42.8 % versus 35.9 %, p = 0.17). Among patients who did not undergo internal ring cauterization during laparoscopic IHR, those who had permanent suture used to close the internal ring had a significantly lower rate of recurrent ipsilateral hernia than those who had absorbable suture used to close the ring (4.5 % versus 20.6 %, p < 0.01 ). Among patients who underwent ring cauterization during laparoscopic IHR, there was no significant association between suture type and incidence of recurrent ipsilateral hernia (p = 0.14; Fig. 2), but very few patients underwent laparoscopic IHR with ring cauterization and absorbable suture (n = 16). The group of 198 patients (38.4 % of all laparoscopic IHRs) who underwent both ring cauterization and permanent suture placement during laparoscopic IHR had a 0.5 % rate of recurrent ipsilateral hernias, which was significantly lower than the cumulative recurrence rate for all other patients undergoing laparoscopic IHR (Figs. 2 and 3) and comparable to patients undergoing open IHR (0.5 % versus 1.2 %, p = 0.40; Fig. 3).
Fig. 2. Rates of recurrent ipsilateral hernias after laparoscopic IHR, by surgical technique.
Laparoscopic IHR with internal ring cauterization and permanent suture to close the internal ring was associated with a significantly lower rate of recurrent ipsilateral hernias than laparoscopic IHR without ring cauterization. Among patients who underwent ring cauterization, the association between suture type and recurrence rate did not reach statistical significance.
Fig. 3. Rates of recurrent ipsilateral hernias after open IHR and laparoscopic IHR (by laparoscopic surgical technique).
Open IHR and laparoscopic IHR with ring cauterization and permanent suture to close the ring were associated with significantly lower rates of recurrent ipsilateral hernias than laparoscopic IHR without both ring cauterization and permanent suture placement (other).
3.4. Impact of technique on outcomes following open IHR
There were 776 patients with a preoperative diagnosis of unilateral hernia who underwent open IHR. Within this group, 357 patients (46.0 %) underwent concurrent diagnostic laparoscopy to examine the contralateral processus vaginalis, resulting in 153 patients undergoing bilateral IHR (40.8 % of patients who had diagnostic laparoscopy performed underwent contralateral IHR during the same procedure). Among patients with a preoperative diagnosis of unilateral hernia who underwent open IHR, the rate of metachronous contralateral hernias in those who had diagnostic laparoscopy performed was significantly lower than in patients who did not undergo diagnostic laparoscopy (1.4 % versus 3.8 %, p = 0.03; Fig. 4) and comparable to the rate of metachronous contralateral hernias discovered after laparoscopic IHR (1.4 % versus 1.2 %, p = 0.79; Fig. 4). Among all 1016 patients who underwent open IHR, the rate of recurrent ipsilateral hernias was 1.1 % after high ligation with absorbable suture and 1.8 % after high ligation with permanent suture (p = 0.54).
Fig. 4. Rates of postoperative metachronous contralateral hernias after laparoscopic IHR and open IHR (with and without diagnostic laparoscopy).
Among patients with a preoperative diagnosis of unilateral inguinal hernia, laparoscopic IHR and open IHR with diagnostic laparoscopy to visualize the contralateral side were associated with significantly lower rates of metachronous contralateral hernias than open IHR without diagnostic laparoscopy.
3.5. Hospital-level comparisons
There were significant differences between participating centers with respect to their case mix of open and laparoscopic IHRs (p < 0.01; Fig. 5). There were also significant differences between centers in utilization of diagnostic laparoscopy during open IHR, as well as frequency of ring cauterization and concurrent permanent suture placement during laparoscopic IHR (p < 0.01; Fig. 5). There were no significant differences between centers in rates of subsequent inguinal hernias (p = 0.31), recurrent ipsilateral hernias (p = 0.75), or metachronous contralateral hernias (p = 0.30). All centers had total rate of subsequent inguinal hernias below 8 %, rate of recurrent ipsilateral hernias below 5 %, and rate of metachronous contralateral hernias below 5 %.
Fig. 5. Differences in operative approach by center.
Participating centers differed in terms of percentage of IHRs performed laparoscopically (A), frequency of diagnostic laparoscopy during open IHR (B), and frequency of internal ring cauterization and concurrent permanent suture placement during laparoscopic IHR (C).
4. Discussion
This multicenter retrospective study on outcomes after primary laparoscopic and open IHR in infants less than 6 months old found that specific intraoperative techniques were associated with reduced incidence of subsequent inguinal hernias. Although there was no significant difference in the overall rate of subsequent inguinal hernias after laparoscopic versus open IHR, there was a significantly greater likelihood of recurrent ipsilateral hernias after laparoscopic IHR and a trend towards a higher rate of metachronous contralateral hernias after open IHR. Importantly, these risks could be mitigated by incorporating specific strategies during laparoscopic and open IHR. Patients who underwent laparoscopic IHR with both internal ring cauterization and permanent suture to close the ring had a significantly lower rate of recurrent ipsilateral hernia than patients who did not have both techniques performed (0.5 % versus 6.3 %, p = 0.01), comparable to the rate of recurrent ipsilateral hernia after open IHR (0.5 % versus 1.2 %, p = 0.40). These findings affirm prior work in animal models that suggests intentional trauma to the internal ring and permanent suture improve durability of laparoscopic IHR [22], and they challenge the dogma that resection of the distal hernia sac is necessary to prevent recurrence of inguinal hernias (at least in infants less than 6 months old). With respect to open IHR, patients who had diagnostic laparoscopy performed to visualize the contralateral side had significantly lower likelihood of metachronous contralateral hernia (1.4 % versus 3.8 %, p = 0.03), comparable to the rate of metachronous contralateral hernia after laparoscopic IHR (1.4 % versus 1.2 %, p = 0.79). This is one of the first studies to demonstrate these associations between intraoperative techniques and long-term outcomes after laparoscopic and open IHR in infants.
Our results highlight the value of internal ring cauterization during laparoscopic IHR but are less clear on the importance of suture type and specific laparoscopic approach, due in large part to the overwhelming popularity of permanent suture and percutaneous repair in this study. With over 90 % of patients in the laparoscopic group undergoing repair with permanent suture, it was difficult to separate the effects of ring cauterization and suture type. Ring cauterization was associated with improved durability of repair: among all patients who had laparoscopic IHR with permanent suture, those who also underwent cauterization of the ring had a significantly lower rate of recurrent ipsilateral hernias than those who did not undergo cauterization (Fig. 2). Permanent suture was also associated with improved durability, but only when cauterization of the ring was not performed (Fig. 2). With only 16 patients undergoing laparoscopic IHR with ring cauterization and absorbable suture, we could not draw conclusions about how permanent suture contributed to durability of repair when cauterization was performed. Since it is not known how permanent suture adjacent to the vas deferens affects long-term fertility, it would be useful to explore outcomes in a larger group of male infants undergoing laparoscopic IHR with ring cauterization and absorbable suture.
Similarly, with over 90 % of laparoscopic IHRs performed percutaneously in this study, we were unable to compare outcomes between percutaneous repair and other laparoscopic approaches (including intracorporeal repair and sac inversion). It is interesting to note that European pediatric surgeons have published excellent outcomes after laparoscopic intracorporeal repair with intentional internal ring trauma and permanent suture, albeit in slightly older children and broader age ranges. Esposito et al., for example, reported no recurrences in 950 consecutive patients repaired in this fashion [7]. Additional studies are necessary to clarify the impact of different laparoscopic approaches on durability of outcomes in infants.
The “optimization” strategies identified in this study—cauterization of the internal ring during laparoscopic IHR and diagnostic laparoscopy during open IHR—were underutilized during the 2018–2019 study period, suggesting opportunity for improved outcomes after IHR in infants. At most participating centers, ring cauterization and permanent suture were used together in fewer than 50 % of laparoscopic IHRs, and diagnostic laparoscopy was performed in fewer than 50 % of open IHRs (Fig. 5). Diagnostic laparoscopy during open IHR remains a point of controversy among pediatric surgeons, and its routine use is limited by a myriad of factors including patient anatomy and ability to tolerate insufflation, integrity of the hernia sac, availability of necessary equipment, and surgeon perspectives on the value of repairing the contralateral patent processus vaginalis. However, cauterizing the internal ring during laparoscopic IHR is technically easy and adds relatively little time or risk to the procedure. In recent multicenter survey studies, about two-thirds of pediatric surgeons who perform laparoscopic IHR reported that they routinely cauterize the internal ring, suggesting that this technique is now relatively common but still far from universal in practice [3,25].
Our results also affirm the rising popularity of laparoscopic IHR among pediatric surgeons in the US, and should be interpreted within this context [2,3,25]. The observed distribution of laparoscopic and open IHRs in this study (33 % of IHRs were performed laparoscopically during 2018–2019) was consistent with PHIS data in infants less than 6 months old during the same two-year interval [2]. This validation of the national database is important, because more recent trends in the PHIS suggest that laparoscopic IHR is now overtaking open IHR as the most popular repair strategy in infants less than 6 months old [2]. We cannot conclude from our retrospective study that one approach is superior to the other, but rather that rates of subsequent inguinal hernias after both open and laparoscopic IHR in infants can be optimized to a similar degree by incorporating specific techniques intraoperatively. However, for a community of pediatric surgeons already shifting toward laparoscopic IHR in infants, our most important finding is that the rate of recurrent ipsilateral hernia after laparoscopic IHR was significantly lower in infants who underwent internal ring cauterization and internal ring closure with permanent suture. Results argue strongly in favor of performing these surgical techniques routinely during laparoscopic IHR to optimize long-term durability. Percutaneous repair was the dominant laparoscopic strategy in this study, so our conclusions are most relevant to this approach.
There were several strengths and limitations inherent to our study design. The inclusion of multiple tertiary children’s hospitals in different regions of the Eastern US provided a broad representation of practices and outcomes in infants. Although rates of laparoscopic versus open IHR, ring cauterization, permanent suture placement, and diagnostic laparoscopy varied between institutions, there were no significant outliers with respect to incidence of subsequent inguinal hernia, and hence no sites that dramatically skewed results. Laparoscopic and open IHR groups were well-matched, but we were unable to account for potentially relevant variables that were difficult to quantify in a multicenter retrospective format, such as relative size of the hernia and dimensions of the internal ring. Patients in this study underwent IHR during 2018–2019, which allowed ample time for subsequent hernias to develop. However, we do not know if patients remained in the same health system during the interval from index operation to data entry, and we could not capture patients who developed recurrent ipsilateral or metachronous contralateral hernias that were treated at outside institutions. Moreover, recurrence rates after laparoscopic IHR in 2018–2019 might not reflect the current reality, as many pediatric surgeons have likely progressed on the learning curve since that time and become more proficient with laparoscopic IHR techniques. Lastly, we did not explore outcomes in older pediatric age groups, and additional studies are necessary to determine if internal ring cauterization and use of permanent suture impact recurrence rates after laparoscopic IHR in older children.
5. Conclusion
This is one of the largest multicenter retrospective studies to date on outcomes after IHR in infants less than 6 months old. Our findings strongly support the use of both internal ring cauterization and permanent suture to close the internal ring during laparoscopic IHR. When performed together, these techniques were associated with significantly lower risk of recurrent ipsilateral hernias in this patient population. Our findings also support the use of diagnostic laparoscopy during open IHR in infants to reduce the risk of metachronous contralateral hernias. Additional studies are necessary to compare outcomes between different laparoscopic approaches, to measure rates of subsequent hernias after laparoscopic IHR in different pediatric age groups, and to clarify how permanent suture during laparoscopic IHR affects both durability of repair and long-term fertility in males.
Supplementary Material
HIGHLIGHTS.
Laparoscopic IHR is common in infants, but data are limited on optimal strategies.
This study examined outcomes after laparoscopic and open IHR in infants <6 months.
Ring cautery and permanent suture during laparoscopic IHR reduced recurrence rate.
Diagnostic laparoscopy during open IHR reduced metachronous contralateral hernia rate.
Results support utilizing these techniques to minimize risk of subsequent hernia.
Funding statement
REDCap is supported by CTSA Grant Number ULI TR003163 from the National Center for Advancing Translational Science (NCATS), a component of the National Institutes of Health (NIH). The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. This research did not receive any additional specific grants from funding agencies in the public, commercial, or not-for-profit sectors.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jpedsurg.2025.162838.
Footnotes
Declaration of interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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