Letter to the Editor Concerning Article by A. A. Wheeler et al (Eur J Pediatr Surg 2011;21:381–385)

The article “Laparoscopic inguinal hernia repair in children with transperitoneal division of the hernia sac and proximal purse string closure of peritoneum: our modified new approach” by A. A. Wheeler et al (Eur J Pediatr Surg 2011;21:381–385) touches upon a crucial technical problem of laparoscopic inguinal hernia repair in children. The article, well made and illustrated with excellent pictures, tempts the writer of this letter to express a warning.

Indeed, in 2012, it is still unknown whether additional peritoneal incisions, either circumferential or partial, will necessarily lead to reduced recurrence rates. It remains an unproven hypothesis.

1. The writer of this letter's department has never made peritoneal incisions (except for some experimenting during the series). And yet his recurrence rate has decreased from initially more than 5% to now approximately 2% during a series of 1400 hernia repairs. He tends to assume that practice and experience alone have decreased the recurrence rate. This does not rule out that incisions might have reduced the rate even further.

2. In reality, our decrease in recurrences has even been more dramatic because we earlier assessed the patients postoperatively in the same manner as the authors did now: we also had mixed up patent processus vaginales (PPVs) and clinical hernias. We also have closed any hole we encountered, and only later we realized that a recurrence rate obtained in this manner is unrealistically low, just because it includes PPVs, not merely true hernias. Subsequently, we only counted true clinical hernias when wanting to know how efficient the laparoscopic approach is for inguinal hernias.

3. Our main reserve, however, against a peritoneal incision is the fact that the authors were using scissors and hook cautery for their maneuvers, with the justification of thereby imitating the “open” approach. We consider the laparoscopic approach's biggest asset the fact that it does not touch the cord structures. Laparoscopic dissection at the inner ring may be difficult (as in the open approach). This is documented by the authors' operating time of 45 minutes for unilateral and 60 minutes for bilateral interventions. True, dissection does produce more scarring than the pure laparoscopic approach, and scarring reduces the recurrence rate. But it concomitantly also imitates the open approach's well-known risk of vessel and vas damage.

In summary, the writer of this letter is afraid that peritoneal incision and dissection, as described by the authors, will trade a lower recurrence rate for a higher rate of vessel and vas lesions.

Conflict of Interest

None