Journal of Pediatric Surgery 49 (2014) 460–464

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Journal of Pediatric Surgery

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Laparoscopic inguinal hernia repair; experience with 874 children

Rafik Shalaby ⁎, Maged Ismail, Abdelhady Samaha, Abdelaziz Yehya, Refaat Ibrahem, Samir Gouda,
Ahmed Helal, Omar Alsamahy
Department of Pediatric Surgery, Al-Azhar University Hospitals, Cairo, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: Background: Laparoscopic inguinal hernia repair (LIHR) in children has become an alternative to the open
Received 1 June 2013 procedure. It is gaining popularity with more and more studies supporting its feasibility, safety, and efficacy.
Received in revised form 23 October 2013 This is a retrospective study to present our experience with children who underwent LIHR.
Accepted 23 October 2013 Patients and methods: A total of 1184 inguinal hernias were repaired laparoscopically in 874 children. They
were 703 boys and 171 girls. Their mean age was 2.9 ± 2.1 years (range, 6–108 months). Six-hundred and
Key words:
twenty four opened internal inguinal rings (IIRs) were closed by transperitoneal purse string suture
Laparoscopy
Reverdin needle
technique (TPP) and 560 opened IIRs were closed by percutaneous purse string suture with lateral umbilical
Congenital inguinal hernia ligament enforcement using Reverdin Needle (RN) technique.
Lateral umbilical ligament Results: All cases were completed laparoscopically without conversion. There were no serious intraoperative
complications. Mean operating time, in TPP technique, was 15 ± 2.3 minutes for unilateral and 20 ± 1.7 minutes
for bilateral inguinal hernia, while the mean operating time, in RN technique, was 8.7 ±1.18 minutes for unilateral
and 12.35 ± 2 minutes for bilateral hernia repair. The contralateral patent processus vaginalis (PPV) was present
in 176 (20% of cases). Follow-up to date is 10–140 months (mean 80 ± 2.1 months). In the early stage of this
study, the recurrence rate was 1.13%. In the last 450 cases, no recurrence occurred. Hydroceles occurred in 0.58%
and no testicular atrophy or iatrogenic ascent of the testis.
Conclusions: LIHR can be a routine procedure with results comparable to those of open procedures. Both
recurrence and operative time are nearly equal or even less than that for the open procedure after gaining a
learning curve and modifications of the techniques.
© 2014 Elsevier Inc. All rights reserved.

Laparoscopic techniques have been applied widely in the man-
agement of various common pediatric surgical conditions. Laparo-
scopic inguinal hernia repair (LIHR) in children has become an
alternative to the conventional open procedure [1–8]. However,
current evidence is insufficient to justify its widespread use in
children and various concerns are raised against the LIHR in children
including: it is more time consuming, it has a higher recurrence rate, it
violates the peritoneal cavity, and there is no overall advantage
compared to the open procedure. It is important to critically evaluate
the effectiveness and the potential risks of new techniques before they
can be accepted as the treatment modality of choice [9,10]. The aim of
this study was to present our experience with children who under-
went LIHR over a period of 12 years.
1. Patients and methods
This study was conducted in Al-Mishary Hospital, Riyadh, Saudi
Arabia, Pediatric Surgery Unit, Al-Azhar University Hospitals and
some private hospitals in Cairo, Egypt between June 2000 and June
⁎ Corresponding author at: Al-Houssain University Hospital, Darrasa, Cairo, Egypt.
Tel.: +20 1000722072; fax: +20 1223975160.
E-mail address: rafikshalaby@hotmail.com (R. Shalaby).
2012. A total of 1184 inguinal hernias were repaired laparoscopically
in 874 children. All children were subjected to full history taking,
thorough clinical examination, and routine laboratory investigations
(CBC, BT, CT, FBS, liver and renal profile). The main outcome
measurements of this study included; operative time, hospital stay,
development of hydrocele, hernia recurrence, testicular atrophy,
iatrogenic ascent of the testis and cosmetic results. The ethical
committee of our hospital approved the study protocol and a written
informed parental consent was obtained.
1.1. Description of the technique
General endotracheal tube anesthesia was used in all cases. An open
Hasson's technique through supra-umbilical incision was used for
creation of pneumoperitoneum to a pressure of 8–12 mmHg. LIHR was
done by 2 different techniques; namely transperitoneal purse string
suture (TPP) technique and percutaneous insertion of purse string
suture around IIR with lateral umbilical ligament enforcement using
Reverdin Needle (RN). In both techniques, extraperitoneal saline was
injected around IIR to facilitate complete encirclement of suture around
IIR safely without leaving a skip area or fearing of injury of spermatic
vessels and vas deferens. Patients were placed supine in the Trendelen-
burg’s position with tilting to the opposite side of the hernia.

0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
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 R. Shalaby et al. / Journal of Pediatric Surgery 49 (2014) 460–464
TPP technique was done according to the technique described by
Chan and Tam [11] with some modifications. A telescope 5-mm, 30
degree was used. Two 3-mm needle holders were inserted directly
without trocars at the mid-clavicular line on both sides at the level of
the umbilicus. Laparoscopy was started by inspection of both IIRs. The
corresponding skin of the hernial defect was first marked by means of
transabdominal illumination of the laparoscope and slight fingertip
external pressure. At the marked site, a 21-gauge needle attached to a
10-cc syringe filled with saline was introduced at 12 o’clock and
advanced along the preperitoneal space on the medial side of the
hernia defect medial to the vas deferens. Then saline was injected
while withdrawing the needle back to the starting point. Then, the
same procedure was repeated along the lateral side of the hernia
defect lateral to the spermatic vessels (Fig. 1). Then 17-mm needle
with non-absorbable mono-filament 2–0 suture was used to close IIR
by a purse string suture starting at 3 o’clock and going all around IIR.
The suture mainly included the subperitoneal tissues except at the
inferior border of IIR where only peritoneum was taken by carefully
picking and lifting it with the tip of left hand needle holder and the
needle was seen all the time beneath the peritoneum (needle sign) to
avoid injury of the spermatic vessels and vas deferens (Fig. 2).
Extracorporeal suture tie was used and before tightening the knot, the
scrotum was squeezed and the intraperitoneal pressure was released
to expel the gas in the hernial sac.
RN technique (Martin Medizin-Technik, D-78501 Tuttlingen,
Germany) was done according to the technique described earlier by
Shalaby et al with some modifications in the form of retroperitoneal
saline injection around IIR and lateral umbilical ligament enforcement
[8,12]. A 3-mm Maryland forceps, holding the tip of a non-absorbable
mono-filament 2–0 thread, was inserted into the abdomen without
trocar at the right mid clavicular line at the level of the umbilicus for
both unilateral and bilateral CIH. A stab incision of the skin was done
(2 cm above and lateral to the IIR on the right side and 2 cm above
and medial to the IIR on the left side) and RN was inserted into the
peritoneal cavity (Fig. 3A–C). The needle was manipulated to pierce
the peritoneum at 3 o’clock on IIR and was advanced to pass through
the inferior margin of IIR under the peritoneum and in front of the
spermatic vessels and vas deferens to pierce the peritoneum at 9
o’clock on the IIR (Fig. 3D–F). Care was taken to avoid damage of the
Fig. 1. Extraperitoneal saline injection around IIR.
461
vas and spermatic vessels by grasping and lifting the peritoneum
away from them and the RN was seen all the time beneath the
peritoneum (needle sign). Then, the side of the hole of RN was opened
and the thread was inserted inside it. Then, the side of the hole was
closed and the needle was withdrawn backward in the same path to
the starting point at 3 o’clock. Then, RN mounted by the thread was
reinserted again at 3 o’clock and was advanced along the superior
margin of the IIR beneath the peritoneum and fascia transversalis to
come out from the same opening at 9 o’clock. The side of the hole of
RN was opened and the short end of the thread was withdrawn out.
RN was withdrawn outside the abdomen and the short end of the
thread was pulled outside the abdominal cavity for extracorporeal
suture tie and pushed by a tie pusher for tightening of the suture
around the IIR (Fig. 4). In both techniques, the airtight tightening of
purse-string knot was stress-tested by raising the intraperitoneal CO2
pressure by 50%. The increase in pressure was sustained for about
30 seconds during which the patient was carefully monitored for
blood pressure, pulse, and oxygen saturation. The air tightness was
confirmed by the absence of hernial sac enlargement with the
increased intraperitoneal pressure. In case of escape of gas into the
hernial sac, a second suture was inserted around IIR
2. Results
A total of 1184 inguinal hernias were repaired laparoscopically in
874 children. The reports of these patients were collected and
analyzed. The demographic data of all patients are shown in
(Table 1). All cases were completed laparoscopically without
conversion. At operation, contralateral PPV was seen and closed in
176 (20%) of cases. Six-hundred and twenty four IIR were closed by
TPP technique and 560 IIRs were closed by percutaneous RN
technique. The mean operating time from skin-to-skin for both
techniques is shown in (Table 1). All patients achieved full recovery
without intraoperative or postoperative complications. In 2 cases,
stress-test resulted in escape of gas into the hernial sac and a second
suture was inserted again around IIR. Most children went home at the
same day. The mean hospital stay was 7.79 ± 1.28 hours (range, 5–
19 hours). Ten percent of children stayed one night postoperatively
because of parental preference, or geographical far distance. Follow-
462 R. Shalaby et al. / Journal of Pediatric Surgery 49 (2014) 460–464
Fig. 2. Needle is safely placed at the elevated peritoneum and traverses just under peritoneum, in front of the spermatic vessels and vas with complete encirclement of the IIR.
up to date is 10–140 months (mean 80 ± 2.1 months). There were
8 recurrences [8/703] (1.13%) in boys and no recurrence in girls. In the
last 450 cases (350 RN and 100 TPP technique), the recurrence rate
was 0%. On follow-up, there were 4 hydroceles [4/703] (0.57%), one
required percutaneous aspiration, and the others responded well to
conservative treatment. There were no instances of postoperative
testicular atrophy or testicular malposition in our series. There was no
metachronous hernia and the cosmetic results were excellent (Fig. 5).
3. Discussion
Laparoscopic inguinal hernia repair is a relatively new procedure
in the pediatric surgical practice. It is rapidly gaining popularity with
more and more studies validating its feasibility, safety, and efficacy. It
has become an alternative to the conventional open procedure [1–
8,13,14]. Advantages of LIHR include excellent visual exposure, the
ability to evaluate the contralateral side, minimal dissection and
avoidance of access trauma to the vas deferens and spermatic vessels,
bladder injuries and iatrogenic ascent of the testis [13,15]. In addition,
it is also helpful in detecting other associated pathology and other
hernias with excellent cosmetic results. It has a comparable operative
time and recurrence rates [7,8,16,17].
Many minimally invasive techniques for addressing pediatric
inguinal hernia have mushroomed in the past two decades. These
techniques vary considerably in their approaches to the internal ring
(intraperitoneal or extraperitoneal), use of ports (three, two, or one),
endoscopic instruments (two, one, or none), sutures (absorbable or
nonabsorbable), and techniques of knotting (intracorporeal or
extracorporeal). A major criticism of the laparoscopic repair remains
its higher recurrence rate, as compared to the traditional open
technique, ranging from 0.83% to 4.1% [7,8,18]. The reasons were
versatile. These include failure to ligate the hernial sac high enough at
Fig. 3. RN is inserted intraperitoneal at 3 o’clock and advanced through the inferior margin of IIR for picking the thread and withdrawn back (A, B, C). Then RN is passing through the
superior margin of the IIR to leave the suture for encircling the IIR (D, E, F).
the IIR, tension at the closure of the internal opening, large hernia,
broken purse-string thread, the suture technical problem and
hematoma formation at the open wound [10]. Generally, the high
recurrence rate in LIHR could possibly be owing to tension at the
closure of the IIR and presence of skip area especially over the vas and
spermatic vessels without complete encirclement of IIR. It appears
that surgeons with more practice have fewer recurrences. Beginners
may not dare to place sutures as closely as required to the vessels
medially. In fact, it was found that recurrences of less experienced
surgeons are high [19]. In this study, all operations were done by the
first and second authors who have an extended experience with
different laparoscopic techniques, specially laparoscopic hernia repair
and that is why we have a very low recurrence in the beginning of this
series and no recurrence in the last 450 cases.
The present study proved that reducing tension on the purse-
string knot when closing the IIR and the addition of the lateral
umbilical ligament to enforce purse-string knot resulted in elimina-
tion of recurrence. A recurrence will not occur if the purse-string knot
and umbilical ligament covering the IIR are confirmed with the stress
test by an increase in the intraperitoneal CO2 pressure at the end of
the operation as stated by Chan [20].
The first large series of intracorporeal repair of CIH was reported
by Schier, with primary closure of the peritoneum lateral to the cord
with interrupted sutures [10]. Then, he modified the technique to use
2-mm instruments without a trocar for intra-abdominal suturing of
the IIR by the placement of 2 Z-sutures [5]. Other modifications
include an N-suture instead of a purse-string suture [6]. Subcutaneous
endoscopic assisted ligation (SEAL) of the hernial sac and other
similar techniques resulted in marked reduction of operative time
when compared to the transperitoneal purse string suture using
standard 3-port technique [8]. Avoiding the vas deferens and gonadal
vessels during the SEAL repair in boys may leave a small gap at the
 R. Shalaby et al. / Journal of Pediatric Surgery 49 (2014) 460–464 463

Table 1
Demographic data of all patients (age, sex, presentations and operative time).

No. of patients 874

No. of opened IIR 1184
Sex
Male 703
Female 171
Age in month Mean, 2.9 ± 2.1 months
6–12 314
12–24 244
24–36 140
N36 176
Presentation
Right sided hernia 460
Left sided hernia 260
Bilateral hernia 134
Fig. 4. The suture is tightened around IIR.
Recurrent hernia 20
Contralateral hernia 176
Operative time RN TPP
internal ring as well as leaving the hernial sac in continuity, which has Unilateral hernia (recurrent or fresh) 8.7 ± 1.18 minutes 15 ± 2.3 minutes
the potential to contribute to a higher incidence of recurrence [21]. Bilateral hernia 12.35 ± 2 minutes 20 ± 1.7 minutes
However, SEAL is associated with a high recurrence rate and
development of granuloma, infection, and skin puckering at the site
of a subcutaneously placed knot [8,22]. These drawbacks of SEAL and recurrence will not occur. They added that their technique has no
other similar techniques were avoided by the use of RN technique. In severe complications and is indicated in the following cases: (1) large
the beginning phase of this study, we had more recurrences (1.13%) in hernia, hernial sac N1.5 cm; (2) recurrent hernia, and (3) the patient’s
boys as of June 2008, excluding the last 450 cases, but this rate is lower age above 5 years [24].
than that reported by others (3.4%–4.1%) performing LIHR [8,10] and In our pediatric surgery unit, Al-Azhar University Hospitals, the IIR
even lower than noted in open herniotomy (1.2%) [18]. Chan and Tam is closed by purse-string suture encircling its whole circumference
stated that injecting normal saline into the extraperitoneal space at IIR without any skip area either by TPP or by RN technique [8]. Both, the
to elevate the peritoneum away from vas and spermatic vessels allows operative time and the recurrence rate in our series are lower than
stitches to be inserted safely without any skip area for a tight purse that reported in the literature because LIHR was started after gaining
string suture. However, care still is needed to make sure the vas good experiences in different laparoscopic procedures. Recently we
deferens and testicular vessels are not included [23]. used an easy, safe, simple and rapid technique for repair of CIH using
Chen et al used medial or lateral umbilical ligaments to cover the percutaneous insertion of purse string suture by RN and extracorpo-
internal hernia opening region after finishing purse-string knot to real suture ligation which is less time consuming. Also, we followed
prevent the recurrence. The method they developed was revolution- many technical refinements such as injecting normal saline into the
ary in the principle of pediatric hernia repair. It includes both the extraperitoneal space at IIR, including sub peritoneal tissue all around
security of repair offered by the watertight closure of the hernia IIR without any skip area, reducing tension on the knot of purse string
opening and the hernia opening region covered with the umbilical suture by deflation of the abdomen and squeezing the scrotum to
ligament flap. The valve mechanism allows scrotal fluid avoiding empty the hernial sac, lateral umbilical ligament enforcement and the
scrotal collection. Under the stress of intra-abdominal pressure, the use of non-absorbable suture. These latest technical refinements and
wall of the sac is pressed over by the flap, keeping the sac in a modifications of the techniques resulted in marked reduction of
collapsed state. They claimed that their technique is very easy and the development of post-operative hydrocele, lowering the recurrence of

Fig. 5. A: Rt. Recurrent huge inguinal hernia. B: Post-operative view.

464 R. Shalaby et al. / Journal of Pediatric Surgery 49 (2014) 460–464
hernia to 0% and reduced operative time. The above mentioned
technical refinements have been described before by Chan and others
[20,23,24]. We have no recurrence in our last 450 LIHR cases as we
followed some technical refinements as described before. Also we
started laparoscopic hernia repair after gaining a good experience in
other laparoscopic techniques. Others have no recurrence in their
series [24–27]. Marte et al stated that the incision of the peritoneum
lateral to the IIR and the W-shaped suture, compared to the sole W-
shaped suture, prevented hernia recurrence in their series [25].
Gorsler and Schier [28] used non-absorbable Z-sutures to close 403
inguinal rings in 279 children. The mean operating time was
14 minutes for unilateral hernias and 21 minutes for bilateral hernias.
They had a recurrence hernia in 3.4% of cases and postoperative
hydroceles in 1.7%. Montupet and Esposito used the laparoscopic
herniorrhaphy by sectioning the sac distally to the inguinal ring and
performing a purse-string suture around the periorificial peritoneum
using a 4/0 nonresorbable suture with a median operating time of
19 minutes. At a follow-up between 1 and 15 years, they have only 11
recurrences (1.5%) [29]. Parelkar et al [9] reported a recurrence rate of
2.9% in the early phase of their study. They claim that the high
recurrence rate could possibly be owing to tension at the closure of
the internal opening and the use of absorbable suture materials.
However, they did not have a recurrence in their last 100 cases and
they presume that this might be attributed to improved learning skills
over time and technical modifications [9]. Methods that allow
complete encircling of the PPV, such as the intraperitoneal purse
string stitch passing between the peritoneum and the cord and vessel
structures so as not to leave any skipped area, or a laparoscopic
technique that produces every step of the open procedure involving
complete division and stitching up of the PPV at the IIR, achieved the
lowest recurrence rate from 0 to 1.3% [25,28].
LIHR in children is known to take longer operative time than open
herniotomy. Many reports showed that it ranged from 25 to
74 minutes. However, the operative time is reduced gradually with
the training curve [5,15,28]. Schier stated that LIHR is not more time
consuming than open techniques. He added that LIHR is quicker than
the open approach especially in male newborns and in bilateral
hernias [10].
It has been stated that after unilateral open herniotomy,
metachronous hernia may occur in up to 30% of cases [30]. Today,
publications are still quoted from the 50s and 60s reporting
contralateral openings in up to 60% [22]. After LIHR, we have never
seen a metachronous hernia within the last 9 years that is because any
open IIR detected during laparoscopy is closed at the same setting.
There is always a risk of intra-abdominal adhesions in open
technique as seen by Schier during the laparoscopic repair of a
metachronous hernia. They found dense intraperitoneal adhesions in
the area of the previously surgically repaired CIH on the other side.
The objection that laparoscopy has a higher risk of adhesions has not
been substantiated. However we did not have a single case of adhesive
obstruction in our series of LIHR and the laparoscopic view of
recurrent right sided hernia after bilateral laparoscopic hernia repair
showed no adhesion on both sides. This disprove the objection
that laparoscopy has high risk of adhesion formation owing to
violation of peritoneal cavity. These observations coincided with that
of Schier [10].
4. Conclusion
LIHR is technically easier and safe owing to better visualization of
all anatomical structures, thus minimizing chances of injury of the vas
deferens and spermatic vessels. Although both recurrences and
operative time were slightly higher in the early stages, now they are
nearly equal or even less than with the open procedure. The risk of
metachronous hernia is reduced. The cosmetic results are excellent
and there are virtually no scars. LIHR can be adopted routinely in
pediatric centers and it can be considered good training for residents
in pediatric surgery because it helps to improve their ability with both
intracorporeal and extracorporeal suture tying.
References
[1] Akansel G, Guvenc BH, Ekingen G, et al. Ultrasonographic findings after
laparoscopic repair of paediatric female inguinal hernias: the vanishing rosebud.
Pediatr Radiol 2003;33:693–6.
[2] Chan KL, Hui WC, Tam PK. Prospective, randomized, single-center, single-blind
comparison of laparoscopic versus open repair of pediatric inguinal hernia. Surg
Endosc 2005;19:927–32.
[3] Esposito C, Montupet P. Laparoscopic treatment of recurrent inguinal hernia in
children. Pediatr Surg Int 1998;14:182–4.
[4] Prasad R, Lovvorn 3rd HN, Wadie GM, et al. Early experience with needlescopic
inguinal herniorrhaphy in children. J Pediatr Surg 2003;38:1055–8.
[5] Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998;33:1495–7.
[6] Schier F. Laparoscopic surgery of inguinal hernias in children: initial experience.
J Pediatr Surg 2000;35:1331–5.
[7] Schier F, Montupet P, Esposito C. Laparoscopic inguinal herniorrhaphy in children:
a three-center experience with 933 repairs. J Pediatr Surg 2002;37:395–7.
[8] Shalaby R, Ismail M, Dorgham A, et al. Laparoscopic hernia repair in infancy and
childhood: evaluation of 2 different techniques. J Pediatr Surg 2010;45:2210–6.
[9] Parelkar SV, Oak S, Gupta R, et al. Laparoscopic inguinal hernia repair in the
pediatric age group–experience with 437 children. Pediatr Surg 2010;45:789–92.
[10] Schier F. Laparoscopic inguinal hernia repair-a prospective personal series of 542
children. J Pediatr Surg 2006;41:1081–4.
[11] Chan KL, Tam PK. A safe laparoscopic technique for repair of inguinal hernia in
boys. J Am Coll Surg 2003;196:987–9.
[12] Shalaby RY, Fawy M, Soliman SM, et al. A new simplified technique for
needlescopic inguinal herniorrhaphy in children. J Pediatr Surg 2006;41:863–7.
[13] Lee Y, Liang J. Experience with 450 cases of microlaparoscopic herniotomy in
infants and children. Pediatr Endosurg Innov Technol 2002;6:25–8.
[14] Bharathi RS, Dabas AK, Arora M, et al. Laparoscopic ligation of internal ring-three
ports versus single-port technique: are working ports necessary? J Laparoendosc
Adv Surg Tech A 2008;18:891–4.
[15] Saranga Bharathi R, Arora M, Baskaran V. Pediatric inguinal hernia: laparoscopic
versus open surgery. JSLS 2008;12:277–81.
[16] De Caluwe D, Cherti B, Puri P, et al. Childhood femoral hernia: a commonly
misdiagnosed condition. Pediatr Surg Int 2003;19:608–9.
[17] Schier F. Direct inguinal hernia in children, the laparoscopic aspect. Pediatr Surg
Int 2000;16:562–4.
[18] Ein SH, Njere I, Ein A, et al. Six thousand three hundred sixty-one pediatric
inguinal hernias: a 35 year review. Pediatr Surg 2006;41:980–6.
[19] Treef W, Schier F. Characteristics of laparoscopic inguinal hernia recurrences.
Pediatr Surg Int 2009;25:149–52.
[20] Chan KL. Laparoscopic repair of recurrent childhood inguinal hernias after open
herniotomy. Hernia 2007;11:37–40.
[21] Ozgediz D, Roayaie K, Lee H, et al. Subcutaneous endoscopically assisted ligation
(SEAL) of the internal ring for repair of inguinal hernias in children: report of a
new technique and early results. Surg Endosc 2007;21:1327–31.
[22] Cushieri A, Szabo Z. Intracorporeal knots in endoscopic surgery. In: Giles GR,
Moossa AR, editors. Essential Surgical Practice. 3rd ed. Oxford, United Kingdom:
Isis Medical Media; 1995. p. 42 [Chap 4].
[23] Chan KL, Tam PK. Technical refinements in laparoscopic repair of childhood
inguinal hernias. Surg Endosc 2004;18:957–60.
[24] Chen K, Xiang G, Wang H, et al. Towards a Near-Zero Recurrence Rate in
Laparoscopic Inguinal Hernia Repair for Pediatric Patients. J Laparoendosc Adv
Surg Tech A 2011;21:445–8.
[25] Marte A, Sabatino MD, Borrelli M, et al. Decreased recurrence rate in the
laparoscopic herniorraphy in children: comparison between two techniques.
J Laparoendosc Adv Surg Tech A 2009;19:259–62.
[26] Becmeur F, Philippe P, Lemandat-Schultz A, et al. A continuous series of 96
laparoscopic inguinal hernia repairs in children by a new technique. Surg Endosc
2004;18:1738–41.
[27] Riquelme M, Aranda A, Riquelme-Q M. Laparoscopic pediatric inguinal hernia
repair: no ligation, just resection. J Laparoendosc Adv Surg Tech A 2010;20:77–80.
[28] Gorsler CM, Schier F. Laparoscopic herniorrhaphy in children. Surg Endosc
2003;17:571–3.
[29] Montupet P, Esposito C. Fifteen years experience in laparoscopic inguinal hernia
repair in pediatric patients. Results and considerations on a debated procedure.
Surg Endosc 2011;25:450–3.
[30] Burd RS, Heffington SH, Teague JL. The optimal approach for management of
metachronous hernias in children: a decision analysis. J Pediatr Surg 2001;36:
1190–5.