Fourteen girls (mean age=6.0±3.3 years; range=11–128 months) were identified for the report. A total of 19 procedures were performed, and the mean operative time was 20±6 min (unilateral, n=9) or 42±7 min (bilateral, n=5). With experience, the surgery time gradually decreased. The mean follow-up period was 12.8±2.5 (range=9–19) months. The patients felt little pain after surgery and so most patients did not need painkiller, and no intraoperative complications associated with the procedure occurred. The cosmetic result was very good in all cases. There were no operative complications and there was no evidence of early recurrence.
Minimal-access surgery has clear advantages in pediatric inguinal hernia repair. Among the various laparoscopic techniques, laparoscopic-assisted percutaneous extraperitoneal closure (LPEC) of the internal ring has become a well-developed technique.
This procedure utilizes the extracorporeal closure of the hernia sac and eliminates the need for intra-abdominal laparoscopic skills compared with the current laparoscopic extraperitoneal closure techniques 1,4,5. The method that we have developed is simple to perform; therefore, this procedure can be recommended for pediatric inguinal hernia. The present data were limited due to the short duration of the follow-up period. A longer follow-up period would enable evaluation of the longer-term recurrence rates. Our modified SEAL technique for the treatment of inguinal hernia in girls proved to be as successful as LPEC and produced excellent cosmetic results.
However, a major criticism of using the SEAL procedure for the repair of inguinal hernias, especially in boys, remains its higher recurrence rate, as compared with LPEC or single-incision LPEC. The incidence of recurrence has been reported as 0–4.3% 4,5,7. In a recent review of recurrences after laparoscopic hernia repair, the most common site of recurrence was along the medial internal ring at the site of the passage of the cord structures 5,11. We believe that, when using single-port techniques with extracorporeal knotting, including the SEAL technique and the percutaneous internal ring suturing technique, passing anterior to the vas deferens and spermatic vessels was the main method to protect them; this could leave a small gap that could lead to recurrence 4,5,7,8,12,13. The potential for recurrence is the limiting factor in both techniques. The original SEAL technique has not been standardized and there can be a high risk for collateral damage and recurrence in inexperienced hands. Actually, there have been no reports about the long-term outcomes from the SEAL technique 7,8,10. Methods of laparoscopic repair have recently evolved toward applying an external purse string suture around the hernia sac, without any division of the sac and leaving no gap 1,9,14. This is the reason we first performed our modified SEAL procedure only in girls to avoid the risk of recurrence and injury to the vas deferens or the blood supply to the testes. This type of damage may cause atrophy and diminished size of the testis, and iatrogenic cryptorchidism. Since the techniques have been established and the operators have become more skilled, we are now planning to extend the procedure to boys.
Our data suggest that the SEAL using miniport is a safe and effective operative procedure compared with other laparoscopic percutaneous extraperitoneal closure procedures and produced excellent cosmetic results for inguinal hernias in girls. We think the SEAL using miniport renders the technique easier and safer by reducing chances of complications. The long-term follow-up of the SEAL using miniport is awaited.
There are no conflicts of interest.
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