potential pitfalls of laparoscopic inguinal hernia repair in children case report of an unrecognized sliding hernia and review of other rare complications

Accepted Manuscript Potential pitfalls of laparoscopic inguinal hernia repair in children: Case report of an unrecognized sliding hernia and review of other rare complications Amanda Dann, Shant Shekherdimian PII: S2213-5766(16)30267-6 DOI: 10.1016/j.epsc.2017.01.008 Reference: EPSC 691 To appear in: Journal of Pediatric Surgery Case Reports Received Date: 30 December 2016 Accepted Date: 22 January 2017 Please cite this article as: Dann A, Shekherdimian S, Potential pitfalls of laparoscopic inguinal hernia repair in children: Case report of an unrecognized sliding hernia and review of other rare complications, Journal of Pediatric Surgery Case Reports (2017), doi: 10.1016/j.epsc.2017.01.008 This is a PDF file of an unedited manuscript that has been accepted for publication As a service to our customers we are providing this early version of the manuscript The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain RI PT ACCEPTED MANUSCRIPT TITLE: Potential pitfalls of laparoscopic inguinal hernia repair in children: Case report of an SC unrecognized sliding hernia and review of other rare complications M AN U AUTHORS: Amanda Dann, MD, Shant Shekherdimian, MD University of California, Los Angeles, Department of Surgery, Division of Pediatric Surgery Corresponding Author: UCLA Surgery-Pediatric BOX 957098, 72-140 CHS 310-206-2429 EP Los Angeles, CA 90095 TE D Shant Shekherdimian, MD AC C SShekherdimian@mednet.ucla.edu RI PT ACCEPTED MANUSCRIPT TITLE: Potential pitfalls of laparoscopic inguinal hernia repair in children: Case report of an SC unrecognized sliding hernia and review of other rare complications M AN U AUTHORS: Amanda Dann, MD, Shant Shekherdimian, MD University of California, Los Angeles, Department of Surgery, Division of Pediatric Surgery Corresponding Author: UCLA Surgery-Pediatric BOX 957098, 72-140 CHS 310-206-2429 EP Los Angeles, CA 90095 TE D Shant Shekherdimian, MD AC C SShekherdimian@mednet.ucla.edu Dann, et al ACCEPTED MANUSCRIPT ABSTRACT: Laparoscopic inguinal hernia repair (LIHR) has been shown to be safe and effective in the pediatric population However, a number of complications exist that are unique to this approach RI PT Here, we provide a review of the the literature of rare complications of LIHR and present a case of an extraperitoneal sliding inguinal hernia containing bladder that was unrecognized at the time of laparoscopic repair While LIHR is associated with low complication rates, our review SC revealed numerous unique complications of LIHR including bowel strangulation secondary to adhesions, port site hernias, omental evisceration, iliac vein puncture with retroperitoneal M AN U hematoma, anesthetic complications and transient or persistent hydrocele In our experience, we encountered an early postoperative “recurrent” hernia which was found to be a sliding hernia not recognized during LIHR This was readily recognized and repaired with the open approach As laparoscopic techniques become increasingly used by pediatric surgeons, it is imperative that TE D both experienced and more novice practitioners of laparoscopy recognize the potential pitfalls unique to laparoscopic repair Introduction: EP KEY WORDS: laparoscopy, inguinal hernia, complications, pediatric AC C Inguinal hernias are a common condition in infancy with an incidence of 1-5% [1,2] This increases dramatically in prematurity, up to 30% in low-weight, preterm infants [3] Given this prevalence, inguinal hernia repair remains one of the most commonly performed pediatric surgical procedures Though traditionally repaired by open technique, laparoscopy was introduced to pediatric inguinal hernia repair in 1997 [4] Since its introduction, numerous laparoscopic methods of repair have been developed utilizing increasingly minimally invasive Dann, et al ACCEPTED MANUSCRIPT techniques While laparoscopic inguinal hernia repair has been shown to be safe and effective in the pediatric population [5,6], there are unique complications associated with this approach Here, we present a case of an unrecognized sliding hernia containing bladder in an infant male RI PT and provide a review of other rare complications of laparoscopic inguinal hernia repair Case Report: Our patient was a month-old male born at 24 weeks gestation after premature rupture of SC membranes The patient was noted to have severe reflux, both clinically and on fluoroscopic imaging, and was dependent on nasojejunal tube feeding Additionally, on exam he was noted to M AN U have a large umbilical hernia and bilateral groin bulges with an ultrasound suggestive of bilateral inguinal hernias containing bowel He was transferred to our quaternary care institution for evaluation for Nissen fundoplication and hernia repair At 19 weeks of age, the patient underwent uncomplicated laparoscopic Nissen fundoplication, TE D laparoscopic-assisted gastrostomy tube placement, bilateral laparoscopic inguinal hernia repair, and umbilical hernia repair Intraoperatively, laparoscopic inspection revealed a large left-sided hernia containing sigmoid colon On the right, a patent processus vaginalis was noted without EP any apparent herniation of intra-abdominal contents After reduction of the left-sided hernia contents, both defects were repaired by closing the peritoneum with a pursestring non- AC C absorbable, monofilament suture The closures were noted to be air tight at the time of the operation The patient’s postoperative recovery was unremarkable However, on postoperative day a voiding urethrocystogram was performed to evaluate for the etiology of recurrent urinary tract infections This revealed bladder herniating into the right inguinal region, consistent with an extraperitoneal sliding hernia (Figure 1) The patient then underwent uncomplicated open right Dann, et al ACCEPTED MANUSCRIPT inguinal hernia repair The bladder was confirmed to be herniating through the direct space and a Bassini repair was performed with absorbable suture Again, the postoperative course was unremarkable RI PT Discussion: While sliding hernias containing bladder account for up to 4% of inguinal hernias in adults [7], this is a rare finding in children Inguinal bladder hernias are classified by their relation to SC the peritoneum Extraperitoneal herniation is well-described in the literature and is thought to be the most rare type [8] Our case highlights a potential pitfall of laparoscopic inguinal hernia M AN U repair, as this type of hernia is not clearly evident from a view inside the peritoneal cavity To the best of our knowledge, this is the first report of this potential complication of laparoscopic repair Proponents of laparoscopic inguinal hernia repair in children assert several advantages over open repair, namely the ability to easily identify and repair metachronous contralateral hernias, TE D lower rates of wound infection, improved cosmesis and superior visualization of the cord structures, while maintaining comparable recurrence and overall complication rates to open repair [9-10] However, while the laparoscopic approach shows some potential benefits over EP open repair, it also introduces the opportunity for novel complications Violation of the peritoneal cavity during laparoscopy presents the possibility of complications AC C not encountered in open repair Several case series report development of port site hernias after laparoscopic repair, sometimes requiring further surgical intervention [11,12] Others cite more morbid complications of peritoneal entry Thomas et al describe a case of omental evisceration through an umbilical port site requiring reoperation for reduction and fascial closure [13] Patkowski et al report a case of adhesive bowel obstruction leading to bowel strangulation and need for laparotomy and resection of 20cm of bowel three months after single port percutaneous Dann, et al ACCEPTED MANUSCRIPT repair The authors state that at the time of operation the strangulated bowel appeared adherent to the site of hernia repair This same patient later underwent laparoscopic lysis of adhesions for recurrent obstructive disease two months after his reoperation [14] RI PT Laparoscopic repair also introduces potentially increased anesthetic complications as it requires general anesthesia while open repair can be performed with sedation and local or regional anesthetic Additionally, CO2 insufflation in children has been linked to hemodynamic SC perturbations as well respiratory challenges, including increased bronchospasm and bronchial secretions [15] While our review did not identify any serious morbidity related to anesthetic M AN U concerns, Turial at al., who focused on laparoscopic repair in infants less than 5kg, cited anesthetic complications in 5% of cases resulting in a need to covert to an open procedure in two [16] Similarly, a series of infants under 3kg undergoing laparoscopic repair reported anesthetic complications resulting in prolonged post-operative intubation in of 67 cases [17] While these TE D studies ultimately conclude that laparoscopic hernia repair is safe and feasible in small infants, this does suggest anesthetic risks should be considered before proceeding with laparoscopic inguinal hernia repair, particularly in low-weight patients EP Hydrocele is another frequently noted minor complication of laparoscopic repair In some series these have been seen to self-resolve over time [11, 14, 18, 19] while others ultimately AC C required aspiration or hydrocelectomy [20, 21] In a series comparing open to laparoscopic technique, transient hydroceles were more common in the laparoscopic cohort Iliac puncture leading to retroperitoneal hematoma has also been noted in single-port and percutaneous ring suturing laparoscopic techniques [13, 22] Additionally, while lower risk of wound complications and improved cosmesis are thought to be benefits of LIHR, wound infections and stitch abscesses or granulomas requiring suture excision have been reported [11, 20, 22] Finally, given Dann, et al ACCEPTED MANUSCRIPT the relatively recent emergence of minimally invasive approaches, it is possible that previously unreported complications may continue to emerge in the literature Conclusion RI PT Laparoscopic inguinal hernia repair is becoming an increasingly popular modality for the management of pediatric inguinal hernias since it was first introduced nearly 20 years ago as more studies demonstrate its feasibility New laparoscopic techniques continue to emerge trying SC to minimize the invasiveness of the procedure while maintaining acceptable rates of recurrence and complications And while laparoscopic repair is generally considered a safe practice with M AN U low complication rates, our review elucidates several examples of unexpected sequelea of this approach As laparoscopic techniques become increasingly used by pediatric surgeons, it is imperative that both experienced and more novice practitioners of laparoscopy recognize the AC C EP TE D unique potential pitfalls Dann, et al ACCEPTED MANUSCRIPT REFERENCES Glick PL, Boulanger S Inguinal hernias and hydroceles In:Grosfeld JL,O’Neill J,Coran A, et al, editors Pediatric surgery, 7th ed Philadelphia: Elsevier; 2012, p 985-1001 RI PT Cox J Inguinal hernia in childhood Surgical Clinics of North America 1985;65: 1331–1342 Harper R, Garcia A, Sia C Inguinal hernia: A common problem of premature infants weighing 1000 grams or less at birth Pediatrics 1975;56:12-15 SC El-Gohary MA Laparoscopic Ligation of Inguinal Hernia in Girls Pediatr Endosurgery Innov Techn 1997;1:185-188 M AN U Esposito C, St Peter SD, Escolino M, Juang D, Settimi A, Holcomb GW 3rd Laparoscopic versus open inguinal hernia repair in pediatric patients: a systematic review J Laparoendosc Adv Surg Tech A 2014;24:811-8 Feng S, Zhao L, Liao Z, Chen X Open Versus Laparoscopic Inguinal Herniotomy in TE D Children: A Systematic Review and Meta-Analysis Focusing on Postoperative Complications Surg Laparosc Endosc Percutan Tech 2015;25:275-80 Madden JL, Hakim S, Agorogiannis AB: The anatomy and repair of inguinal hernias Surg EP Clin North Am 1971;51:1269-1292 Soloway HM, Portney F, Kaplan A Hernia of the bladder J Urol 1960;84:539–43 AC C Saranga Bharathi R, Arora M, Baskaran V Pediatric inguinal hernia: laparoscopic versus open surgery JSLS 2008;3:277-81 10 Yang C, Zhang H, Pu J, Mei H, Zheng L, Tong Q Laparoscopic vs open herniorrhaphy in the management of pediatric inguinal hernia: a systemic review and meta-analysis J Pediatr Surg 2011;9:1824-34 Dann, et al ACCEPTED MANUSCRIPT 11 Choi W, Hall NJ, Garriboli M, et al Outcomes following laparoscopic inguinal hernia repair in infants compared with older children, Pediatr Surg Int 2012;28:1165–1169 12 Steven M, Carson P, Bell S, Ward R, McHoney M Simple Purse String Laparoscopic Versus RI PT Open Hernia Repair J Laparoendosc Adv Surg Tech A 2016;2:144-7 13 Thomas DT, Göcmen KB, Tulgar S, Boga I Percutaneous internal ring suturing is a safe and with 250 cases J Pediatr Surg 2015;15:824-6 SC effective method for the minimal invasive treatment of pediatric inguinal hernia: Experience 14 Patkowski D, Czernik J, Chrzan R, Jaworski W, Apoznański W Percutaneous internal ring M AN U suturing: a simple minimally invasive technique for inguinal hernia repair in children J Laparoendosc Adv Surg Tech A 2006;16:513-7 15 Sfez M, Guerard A, Desruelle P et al Cardiorespiratory changes during laparoscopic fundoplication in children Paediatr Anaesth 1995;5: 89–95 TE D 16 Turial S, Enders J, Krause K, Schier F Laparoscopic inguinal herniorrhaphy in babies weighing kg or less Surg Endosc 2011;25:72–78 17 Esposito C, Turial S, Escolino M, et al Laparoscopic inguinal hernia repair in premature EP babies weighing kg or less Pediatr Surg Int 2012;28:989-92 18 Montupet P, Esposito C Fifteen years experience in laparoscopic inguinal hernia repair in AC C pediatric patients Results and considerations on a debated procedure Surg Endosc 2011;25:450-3 19 Saranga Bharathi R, Arora M, Baskaran V Pediatric inguinal hernia: laparoscopic versus open surgery JSLS 2008;12:277-81 Dann, et al ACCEPTED MANUSCRIPT 20 Shalaby R, Ismail M, Samaha A, Yehya A, Ibrahem R, Gouda S, Helal A, Alsamahy O Laparoscopic inguinal hernia repair; experience with 874 children J Pediatr Surg 2014;49:460-4 hernia repair in 495 children Surg Endosc 2015;29:781-6 RI PT 21 McClain L, Streck C, Lesher A, Cina R, Hebra A Laparoscopic needle-assisted inguinal 22 Chang YT, Lee JY, Tsai CJ, Chiu WC, Chiou CS Preliminary experience of one-trocar SC laparoscopic herniorrhaphy in infants and children J Laparoendosc Adv Surg Tech A AC C EP TE D M AN U 2011;21:277-82 Dann, et al ACCEPTED MANUSCRIPT M AN U SC RI PT Figure AC C EP TE D Image from voiding cystourethrogram showing a portion of the bladder herniating into the right groin  ... present a case of an unrecognized sliding hernia containing bladder in an infant male RI PT and provide a review of other rare complications of laparoscopic inguinal hernia repair Case Report: ... ACCEPTED MANUSCRIPT TITLE: Potential pitfalls of laparoscopic inguinal hernia repair in children: Case report of an SC unrecognized sliding hernia and review of other rare complications M AN U AUTHORS:... report of an SC unrecognized sliding hernia and review of other rare complications M AN U AUTHORS: Amanda Dann, MD, Shant Shekherdimian, MD University of California, Los Angeles, Department of