Long-term follow-up of laparoscopic transcutaneous inguinal herniorraphy with high transfixation suture ligature of the hernia sac Matias Bruzoni, Joshua D. Jaramillo, Zachary J. Kastenberg, James K. Wall, Robert Wright, Sanjeev Dutta ⁎ Division of Pediatric Surgery, Lucile Packard Children's Hospital, Department of Surgery, Stanford University School of Medicine, Stanford, CA abstract article info Article history: Received 5 December 2014 Received in revised form 3 June 2015 Accepted 8 June 2015 Available online xxxx Key words: Inguinal hernia Herniorrhaphy Laparoscopic Recurrence Pediatric Children Background: Laparoscopic transcutaneous inguinal hernia repair in children may reduce postoperative pain, im- prove cosmesis, allow for less manipulation of the cord structures, and offer easy access to the contralateral groin. However, there is concern for unacceptably high recurrence rates when the procedure is generalized. To address this increase in recurrence, in 2011 we described in this journal a modification of the laparoscopic transcutaneous technique that replicates high transfixation ligature of the hernia sac with the aim of inducing more secure healing, preventing suture slippage, and distributing tension across two suture passes. We now describe our long-term follow-up of this novel repair. Methods: After obtaining IRB approval, a retrospective chart review and phone follow-up were performed on all patients who underwent laparoscopic transfixation ligature hernia repair between October 2009 and August 2014 (including further follow-up of the 21 patients reviewed in the 2011 report of this technique). Data collec- tion included demographics, laterality of hernia, evidence of recurrence, complications, and time to follow-up. Results: Median follow-up was 24 months (range 2–52 months). Three pediatric surgeons performed 216 laparoscopic transfixation ligature repairs on 166 patients. Demographics: mean age 29.5 months (range 1– 192 months); male 67.2% and female 32.8%; 4.2% of patients were premature at operation. Repairs were bilateral in 42% of patients, right sided in 34%, and left sided in 24%. Three patients together experienced 4 recurrences, for an overall recurrence rate of 1.8%. Two of the recurrences occurred in a 2-month old syndromic patient with se- vere congenital heart disease who recurred twice after laparoscopic transfixation ligature repair then subse- quently failed an attempt at open repair. Excluding this one outlier patient, the recurrence rate was 0.9%. The complication rate was 1.7% (3 hydroceles and 1 inguinal hematoma; all resolved spontaneously). Conclusion: Laparoscopic high transfixation ligature hernia repair can be adopted by surgeons with basic laparo- scopic skills, and result in excellent outcomes with acceptable recurrence rates. © 2015 Elsevier Inc. All rights reserved. The traditional open hernia repair, which has recurrence rates of approximately 1% [1], is being supplanted by a multitude of minimal ac- cess surgery (MAS) techniques at a number of institutions. Laparoscopic inguinal hernia repair in children may reduce postoperative pain, im- prove cosmesis, allow for less manipulation of the cord structures, and offer easy access to the contralateral groin [2–4]. The two most com- monly used MAS techniques include the transabdominal approach with intracorporeal suturing, and the transcutaneous approach, of which there are a number of variations [2–7]. Such MAS approaches have a steep learning curve. However, recurrence rates in some series have approximated that of the open repair when performed by experi- enced surgeons, ranging from 1.13% to 4.3% [4,5,7]. In 2009, we de- scribed a single surgeon experience of a laparoscopic transcutaneous simple ligature hernia repair with recurrence rates comparable to the open repair [4]. However, when this procedure was generalized to all the surgeons in our practice, our recurrence rates increased to about 4% (unpublished data). It has been suggested that in addition to surgeon experience, certain anatomic features (large hernia defect, thick abdominal wall, etc.) are more difficult to repair laparoscopically and thus contribute to the higher rate of recurrence [6]. Knot slippage, a “seton-like” effect where the suture cuts through peritoneal tissue, and increased tension distrib- uted across only one suture have been anecdotally implicated in ob- served failures. In 2011, our institution described a modification of the laparoscopic transcutaneous technique that replicates high transfixation ligation of the hernia sac with the aim of inducing more secure healing, preventing suture slippage, and distributing even tension across two suture passes (Fig. 1) [8]. This modification of the transcutaneous technique intends to overcome the above difficulties and more closely replicate the suture li- gation of the hernia sac used during a traditional open repair, although it stops short of the herniotomy that typically accompanies open repair. We now describe our long-term follow-up of patients undergoing this novel repair. Journal of Pediatric Surgery xxx (2015) xxx–xxx ⁎ Corresponding author at: Division of Pediatric Surgery, Lucile Packard Children's Hos- pital, Department of Surgery, Stanford University Medical Center, 777 Welch Rd-Ste J, Stanford, CA 94305. Tel.: +1 650 723 6439; fax: +1 650 724 5344. E-mail address: sdutta1@stanford.edu (S. Dutta). http://dx.doi.org/10.1016/j.jpedsurg.2015.06.006 0022-3468/© 2015 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg Please cite this article as: Bruzoni M, et al, Long-term follow-up of laparoscopic transcutaneous inguinal herniorraphy with high transfixation suture ligature of the hernia sac, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.06.006