1. a
Zagazig University, Faculty of
Medicine, Dept. of Urology,
Zagazig, Egypt
b
Benha University, Faculty of
Medicine, Dept. of General
Surgery, Egypt
Correspondence to:
A.M.N. Sakr, Zagazig University,
Faculty of Medicine, Dept. of
Urology, Zagazig 44519, Egypt,
Tel.: þ20 1005677850, þ20
1112237050
hsurgeon71@gmail.com
(H. Ahmed)
mamar1973@yahoo.com
(M.K. Youssef)
dr_emadsalem@yahoo.com
(E.A. Salem)
amrfawzi_uro@hotmail.com
(A.M. Fawzi)
prof_esam_desoky@yahoo.
com (E.A.E. Desoky)
ahmedeliwafarag@gmail.
com (A.M. Eliwa)
ahmedsakr_1980@yahoo.
com (A.M.N. Sakr)
ashrf1959@gmail.com
(A.M.S. Shahin)
Keywords
Laparoscopically assisted; High
ligation; Patent processus
vaginalis; Children
Received 8 September 2014
Accepted 6 May 2015
Available online xxx
Efficacy of laparoscopically assisted high
ligation of patent processus vaginalis in
children
H. Ahmed b
, M.K. Youssef a
, E.A. Salem a
, A.M. Fawzi a
,
E.A.E. Desoky a
, A.M. Eliwa a
, A.M.N. Sakr a
, A.M.S. Shahin a
Summary
Introduction
Laparoscopic hernia repairs have been proven to be
efficient and safe for children, despite the slightly
higher recurrence rate compared with the classic
surgical repair. They have the advantage of easy and
precise identification of the type of defect and its
correction, both in ipsilateral and contralateral
sides.
Objectives
The objectives of this study were to evaluate the
efficacy, safety and outcome of the laparoscopically
assisted piecemeal high ligation of a patent proc-
essus vaginalis (PPV) in children.
Methods
A total of 40 children were enrolled into this pro-
spective study; they were aged !6 months and had
an inguinal hernia. The peritoneal cavity, including
the contralateral side, was inspected for the possi-
bility of bilateral hernias using a 3-mm 30
tele-
scope. Another 3-mm port was introduced through
the same infra-umbilical incision. The hernia was
manually reduced or with the aid of a working infra-
umbilical grasper. A prolene or vicryl 2/0 or 3/0 su-
ture on a curved semicircle round-bodied taper-
ended 25e30 mm needle was introduced through a
very small inguinal skin-crease incision. It was
passed through the abdominal wall layers to the
peritoneum and was manipulated by the laparo-
scopic grasper to pick up the peritoneum in
piecemeal all around the internal ring. The needle
was then pushed to the outside near to the entrance
site, thus forming a semicircle around the internal
ring. The suture was then tied and the knot was
subcutaneously buried.
The primary outcome of the procedure was the
incidence of intraoperative diagnosis and surgical
repair of contralateral hernias in pre-operatively
diagnosed unilateral cases. The secondary outcomes
were defined as the incidence of complications and
hernia recurrence.
Results
Discussion
The exploratory laparoscopy found contralateral
patent processus vaginalis (CPPV) with a detection
rate of 28.1%. Chan et al., Esposito et al., Toufique
et al. and Niyogi et al. reported similar figures for
laparoscopic contralateral hernia detection rates of
28%, 39%, 39.7% and 29.2%, respectively.
The limitations of this study were the small
sample size, plus the risk factors and clinical sig-
nificance for CPPV.
Conclusion
Laparascopically assisted piecemeal closure of the
internal inguinal ring in children is a safe and
effective procedure. It helps in detecting a contra-
lateral hernia without prolonging the operative
time.
Table Patients demographics, operative time and post-operative hospital stay.
Age (years) 3.4 Æ 1.8
Side Right 28 (48.3%)
Left 20 (41.7%)
Laterality Pre-operative Unilateral 32 (80%)
Bilateral 8 (20%)
Intra-operative Unilateral 23 (67.5%)
Bilateral 17 (32.5%)
Operative time (minutes) Unilateral 25 Æ 4
Bilateral 34.6 Æ 3.8
Hospital stay (hours) 4.3 Æ 1.5
+ MODEL
Please cite this article in press as: Ahmed H, et al., Efficacy of laparoscopically assisted high ligation of patent processus vaginalis in
children, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.05.036
http://dx.doi.org/10.1016/j.jpurol.2015.05.036
1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Journal of Pediatric Urology (2015) xx, 1.e1e1.e5

2. Introduction
Laparoscopy has been a corner stone in the diagnosis and
management of impalpable testes in children. The increased
use of laparoscopic techniques in managing different urologic
diseases has provided many benefits for children [1]. The
routine method of surgical treatment for patent processus
vaginalis in children has been herniotomy through an inguinal
incision [2]. The reported recurrence rate for conventional
open hernia repair in children is 0.8e3.8% and the post-
operative contralateral hernia rates are 5.6e30% [3]. How-
ever, the trend has moved towards the application of
laparoscopic techniques for pediatric hernia repairs [4].
Laparoscopic hernia repair in children has proven to be
efficient and safe, despite the slightly higher recurrence
rates compared with the classic surgical repair [5]; it has
the advantage of easy and precise identification of the type
of defect and its correction, both in ipsilateral and
contralateral sides. Modern laparoscopic techniques have
made ligation of the internal ring with a single port more
feasible [6]. The debate about whether the laparoscopic
approach for an indirect inguinal hernia should replace the
standard surgical procedure still exists. The present study
aimed to evaluate the efficacy, safety and outcome of the
laparoscopically assisted piecemeal high ligation of a pat-
ent processus vaginalis in children.
Patient and methods
This prospective study was conducted from October 2009 to
March 2011 after approval from the institution ethics
research committee. Informed, written patient consent was
obtained from all participants. Forty children aged !6
months and with an inguinal hernia, irrespective of laterality,
were enrolled into the study. All children underwent com-
plete physical examination and pre-operative laboratory in-
vestigations. Inclusion criteria were children with an
indication for hernia repair and having no contraindication to
perform a laparoscopy. Children with coagulopathy and those
with complicated hernias or hernias associated with other
inguino-scrotal swellings were excluded from the study.
Data were checked, entered and analyzed using SPSS
software (SPSS, Chicago, IL, USA, version 20). Quantitative
data were expressed as mean Æ standard Deviation (SD),
while qualitative data were number or ratio.
Operative procedure
All children received general inhalational endotracheal
anesthesia with muscle relaxation and were placed in a slight
Trendelenburg position during the procedure. A urethral
Foley catheter of appropriate size was fixed. Pneumo-
peritoneum was established with an open technique by
introducing a 3-mm reusable trocar through a transverse
infra-umbilical incision. The insufflation pressure was
adjusted between 8 and 10 mmHg, according to the patient’s
age. The peritoneal cavity was inspected using a 3-mm 30
telescope, including the contralateral side for the possibility
of bilateral hernias. Another 3-mm port was introduced
through the same infra-umbilical incision. The hernia was
manually reduced or with the aid of the working infra-
umbilical grasper. Under laparoscopic monitoring, a 10-cc
local anesthetic (lidocaine 0.5%) and saline mixture in 1:1
ratio were extraperitoneally injected at the site of the in-
ternal ring, creating an extraperitoneal space for needle
passage without endangering the vas and vessels, and helping
in the control of postoperative pain. A prolene or vicryl 2/0 or
3/0 suture on a curved semicircle round-bodied taper-ended
25e30 mm needle was introduced through a very small
inguinal skin crease incision using a needle holder. It was
passed through the abdominal wall layers to the peritoneum
and was manipulated by the laparoscopic grasper to pick up
the peritoneum in piecemeal all around the internal ring. The
needle was then pushed to the outside near to the entrance
site, thus forming a semicircle around the internal ring. The
suture was then tied and the knot was subcutaneously buried
(Fig. 1 and Fig. 2). All needle movements, starting from
insertion to finishing outside of the body cavity, were lapa-
roscopically guided. Prior to the tightening of the purse-string
suture, laparoscopic revision of the internal ring structures
was conducted to assure that none were included in the su-
ture or injured during needle movement. Skin incisions were
closed using vicryl 4/0 subcuticular sutures. Bilateral hernias
that had been pre-operatively or intraoperatively diagnosed
were simultaneously managed during the same procedure.
The operative time was defined as the time starting from port
insertion until the end of deflation and closure of the wound.
The primary outcome of the procedure was the inci-
dence of intraoperative diagnosis and surgical repair of
contralateral hernia in pre-operatively diagnosed unilateral
cases. The secondary outcomes were defined as the inci-
dence of intraoperative and immediate postoperative
complications, and incidence of hernia recurrence.
Results
The study included 40 children: 26 males and 14 females
with a mean age of 3.4 Æ 1.8 years (range 6 monthse7
years). A pre-operative inguinal examination detected
bilateral hernias in eight children (20%) e five males and
three females (Table 1).
Figure 1 Piecemeal closure of the internal inguinal ring.
Source: authors’ own photo.
1.e2 H. Ahmed et al.
+ MODEL
Please cite this article in press as: Ahmed H, et al., Efficacy of laparoscopically assisted high ligation of patent processus vaginalis in
children, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.05.036

3. All children had a smooth procedure with no intra-
operative complications and no conversion to open surgery.
Nine children (28.1%) with unilateral hernias (six right and
three left) were found to have a synchronous contralateral
hernia, which was intraoperatively diagnosed. Therefore, a
total or 57 hernias were repaired.
The mean operative time was 25 Æ 4 (range 13e37)
minutes for unilateral cases and 34.6 Æ 3.8 (range 23e48)
minutes for bilateral cases. No children had immediate
postoperative complications, and any mild-to-moderate
pain responded to non-steroidal anti-inflammatory drugs.
The mean postoperative hospital stay was 4.3 Æ 1.5 (range
2e8) hours (Table 2).
The mean follow-up period was 18.5 Æ 5.4 (range 12e30)
months. One child with a bilateral hernia developed uni-
lateral recurrence 4 months after surgery and was
conventionally managed using an open approach. No
contralateral or ipsilateral, direct or indirect inguinal her-
nias developed in the unilateral cases. No cases of testic-
ular atrophy were reported.
Discussion
Laparoscopy is a minimally invasive surgery with rapid
postoperative recovery and return to usual daily activities,
and with minimal, cosmetically acceptable scars. Children
are good candidates to benefit from these advantages [7].
In the present study, an exploratory laparoscopy was
conducted for 32 children who were clinically diagnosed as
having a unilateral inguinal hernia. Nine of them were
found to have a contralateral hernia, with a detection rate
of 28.1%. Chan et al. [8], Esposito et al. [9], Toufique et al.
[10] and Niyogi et al. [11] reported similar figures for
laparoscopic contralateral hernia detection rates of 28%,
39%, 39.7% and 29.2%, respectively.
The laparoscopic exploration of the contralateral inguinal
region neither prolonged the operative time nor added
complications, so it can be considered to be cost effective
and sparing any unnecessary secondary inguinal surgery. This
finding is consistent with Guner et al. [12] and Lee et al. [13].
All procedures were safely performed without any
intraoperative complications related to anesthesia, peri-
toneal insufflations or the surgery itself. In the present
study, the mean operative time was 25 and 35 min for
unilateral and bilateral cases, respectively, which was in
line with that reported by Parelkar et al. [14], Esposito
et al. [15] and Giseke et al. [16], who reported mean
operative times of 23, 7e30 and 26.2 min for unilateral and
29, 12e42 and 34.5 min for bilateral hernia, respectively.
In the present study, the mean postoperative hospital
stay was 3.4 h (range 2e8 h). The management of laparo-
scopic inguinal hernial repair as a day-case coincided with
that reported by Parelkar et al. [14] and Giseke et al. [16].
It is proven that laparoscopic hernia repair is a method
that can avoid all the possible causes of recurrence in open
Figure 2 Internal inguinal ring after closure.
Source: authors’ own photo.
Table 1 Children’s characteristics and clinical data.
Male Female Total
Number (%) 26 (65%) 14 (35%) 40 (100%)
Age Mean Æ SD (years) 3.6 Æ 1.5 3.3 Æ 2.1 3.4 Æ 1.8
Age strata 1 year 2 (7.7%) 1 (7.2%) 3 (7.5%)
1e3 years 11 (42.3%) 7 (50%) 18 (45%)
3e5 years 9 (34.6%) 3 (21.4%) 12 (30%)
5 years 4 (15.4%) 3 (21.4%) 7 (17.5%)
Laterality Unilateral 21 (80.8%) 11 (78.6%) 32 (80%)
Bilateral 5 (19.2%) 3 (21.4%) 8 (20%)
Side Right 18 (58.1%) 10 (58.8%) 28 (48.3%)
Left 13 (41.9%) 7 (41.2%) 20 (41.7%)
Table 2 Operative and hospital stay data.
Hernia laterality Pre-operative Unilateral 32 (80%)
Bilateral 8 (20%)
Intraoperative Unilateral 23 (67.5%)
Bilateral 17 (32.5%)
Total number of hernias 57
Operative time (minutes) Unilateral 25 Æ 4 (13e37)
Bilateral 34.6 Æ 3.8 (23e48)
Hospital stay Mean Æ SD (hours) 4.3 Æ 1.5
Range (hours) 2e8
Time strata 3 h 8 (20%)
3e6 h 28 (70%)
6 h 4 (10%)
Efficacy of laparoscopically assisted high ligation of PPV 1.e3
+ MODEL
Please cite this article in press as: Ahmed H, et al., Efficacy of laparoscopically assisted high ligation of patent processus vaginalis in
children, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.05.036

4. surgery [8]. In the present study, only one child had a
recurrent hernia, giving a frequency of 2.5% for children
and 1.75% for repaired hernias. The reported recurrence
rate goes in hand with that previously reported by Niyogi
et al. [11] and Parelkar et al. [14].
To overcome the reported [17] relatively high recur-
rence rate in children’s laparoscopic hernia repair using an
intracorporeal suturing technique, the applied procedure
was conducted through an extracorporeal approach. The
present technique of ligating the internal ring seems to be
simpler and does not need any specially designed in-
struments. This is in comparison with Tam et al. [18] who
used the hook method during hernia repair to allow
extraperitoneal passage of the suture to close the hernia
sac.
Endo et al. [19] described a method that needs a
specially designed needle and the stitch around the internal
ring is laparoscopically tied, with the possibility that it may
loosen. Bharathi et al. [20] assessed the differences in
outcome between the three-port technique and the single-
port laparoscopically assisted ligation technique, and found
that both are safe and efficacious day-case procedures. In
the present study, the operative time was comparable to
that reported in the literature for the three-port technique
and was without difficulty in visualization during the pro-
cedure [20].
Rothenberg et al. [6] tried to determine the safety and
efficacy of limited-access laparoscopic procedures in chil-
dren by using a modified single-port technique and found it
to be a safe and viable alternative to a standard laparo-
scopic approach for some procedures in children. The pri-
mary advantage was cosmetic scar, however, they stated
that visualization and tissue manipulation were more
difficult and time consuming. They assumed that the
addition of a single 3-mm instrument at a separate site
allows for easier dissection and triangulation, with almost
no visible scarring. It is worth noting that Rothenberg et al.
[6] described their experience using a single port for various
operative procedures without focusing on hernia repair.
The current study found no need for an additional port, as
the vision was clear with satisfactory manipulation.
Conclusion
Laparascopically assisted, piecemeal closure of the internal
inguinal ring in children is a safe and effective day-case
procedure, with satisfactory cosmetic appearance. It helps
in detecting a contralateral hernia without prolonged
operative time.
Conflict of interest
There was no direct or indirect commercial financial
incentive associated with publishing this article. No funding
agreement limits the ability to complete and publish this
research/study. There is full control of the primary data.
Funding
None.
Ethical approval
The institutional ethics committee approved this study.
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children, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.05.036

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Efficacy of laparoscopically assisted high ligation of PPV 1.e5
+ MODEL
Please cite this article in press as: Ahmed H, et al., Efficacy of laparoscopically assisted high ligation of patent processus vaginalis in
children, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.05.036