Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) for an Inguinal Hernia in a Pediatric Female

Pediatric inguinal hernias are indirect, resulting from a persistent patent processus vaginalis (PPV). These hernias will not spontaneously heal and carry a serious, persistent risk of incarceration. Consequently, surgical repair is typically advised soon after diagnosis to minimize the risk of incarceration.

This report details a 4-year-old girl with a reducible left inguinal hernia containing the greater omentum. Treatment options include the standard open inguinal herniorrhaphy or the minimally invasive laparoscopic percutaneous extraperitoneal closure (LPEC).

Open repair remains a widely accepted, safe, and cost-effective approach with excellent cosmetic outcomes, and thus continues to serve as a reliable standard technique. LPEC offers improved visualization, superior cosmetic results, and the ability to identify and repair contralateral PPV during the same procedure, which reduces the risk of metachronous hernia—particularly in girls, where the technique is technically straightforward. Based on accumulated experience and consistently favorable outcomes, it has become our routine approach for pediatric inguinal hernia repair.

The LPEC technique utilizes a specialized device, the Lapa-Her-Closure. The success of this procedure relies on several key technical steps, particularly in female patients:

• Needle Rotation: Rotation of the needle tip is the most critical step—clockwise on the right side and counterclockwise on the left. This rotation facilitates smooth advancement through the preperitoneal space by creating a wider dissection plane.
• Vessel Preservation: The rotation and careful advancement aim to avoid injury to the external iliac vessels posteriorly, while directing the needle medially toward the round ligament of the uterus.
• Precise Ligation: Ensure that only the peritoneum is encircled by the suture, excluding adjacent structures such as preperitoneal fat or muscle, to achieve a tight and effective high ligation.

LPEC is a fundamental, safe, and effective technique ensuring proper closure and excellent long-term prognosis.

Pediatric surgery; pediatric inguinal hernia; female; LPEC, Lapa-Her-Closure.

In contrast to inguinal hernias in the adult population, up to 99% of inguinal hernias in children are indirect, resulting from a patent processus vaginalis (PPV).¹ During embryological development, an outpouching of the peritoneum, known as the processus vaginalis, forms along the gubernaculum and accompanies the round ligament in females. If this structure fails to obliterate, it persists as a PPV, which resides within the inguinal canal alongside the round ligament of the uterus.² Consequently, definitive repair of pediatric inguinal hernias is performed by high ligation of the hernia sac without mesh reinforcement, which is typically required in adult direct hernias due to posterior wall weakness. The incidence of incarceration in unrepaired hernias has been reported to be approximately 7% among all pediatric patients, rising to 11% in preterm infants.³ This approach effectively eliminates the risk of bowel or gonadal incarceration through childhood and into early adult life.⁴

This report describes the case of a 4-year-old girl who presented with a bulging mass in the left inguinal region, which had first been noted approximately one week prior to her initial visit to our hospital. According to her mother, the mass had initially been difficult to reduce but would spontaneously disappear when the patient was in the supine position. Since that time, the bulge had been observed on a daily basis, prompting her mother to consult a local clinic. There, an inguinal hernia was suspected, and the patient was subsequently referred to our hospital for further evaluation.

The symptoms had not progressed to incarceration, and the patient exhibited no signs of pain or gastrointestinal distress at the time of referral.

On physical examination, a bulging mass was prominently observed in the left inguinal region while the patient was in the standing position, whereas no abnormal findings were noted on the contralateral side. The mass spontaneously reduced when the patient assumed the supine position, consistent with a reducible hernia.

These findings were sufficient to establish the clinical diagnosis of an inguinal hernia, in accordance with standard pediatric surgical practice.

Although the diagnosis of inguinal hernia is primarily clinical, ultrasonography confirmed the diagnosis of a left indirect inguinal hernia, revealing protrusion of the greater omentum through a PPV, which was reducible with gentle pressure. No contralateral hernia was detected on screening.

In our institution, ultrasound is routinely used as a supplementary tool to visualize the herniated contents and to provide diagnostic reassurance in cases where external findings are subtle, while fully acknowledging that clinical examination alone is typically sufficient for diagnosis.

In pediatric patients, inguinal hernias generally do not resolve spontaneously and tend to enlarge over time. The bulging mass often becomes more noticeable and increases in size with increases in intra-abdominal pressure (e.g., crying, coughing, straining, or defecation).⁵ There is also a risk of incarceration or strangulation of the herniated contents, which necessitates surgical intervention once diagnosed.³

Following surgical repair, pediatric inguinal hernias generally have an excellent prognosis. Recurrence rates are low, typically less than 2%, and postoperative complications, such as infection or hematoma, are generally uncommon in the inguinal region.^3,5 Umbilical port–site infections may occur more frequently in laparoscopic repairs, although these are usually mild and self-limited.

Most children can resume normal activities within a week. Proper surgical closure effectively prevents recurrence, incarceration, and long-term functional impairment.

These principles apply regardless of whether the repair is performed using an open or laparoscopic technique, as both approaches aim to eliminate the risk of incarceration during childhood.

Surgical repair, referred to as herniorrhaphy, is characterized by high ligation of the hernia sac at the level of the internal inguinal ring. The principal surgical approaches include:⁵

• Open Inguinal Herniorrhaphy: This traditional approach is safe and highly effective. It involves a small incision in the groin, dissection of the hernia sac, and high ligation. Open repair remains a widely practiced technique worldwide and is considered the standard approach in many centers due to its reliability, cost-effectiveness, and excellent outcomes.
• Laparoscopic Percutaneous Extraperitoneal Closure (LPEC): This minimally invasive technique uses a laparoscopic camera and a percutaneous needle system to achieve high ligation of the hernia sac. Laparoscopy also allows direct inspection of the contralateral internal ring, which can be useful in patients at risk of bilateral disease.

The decision to surgically manage pediatric inguinal hernias is based on two crucial facts: the hernia will not spontaneously resolve, and there is a serious, persistent risk of incarceration. Incarceration constitutes an acute surgical emergency as it consistently poses a risk of ischemic injury to the herniated contents, notably the bowel. In female patients, the hernia sac often contains reproductive organs such as the ovary or fallopian tube, and prolonged incarceration may lead to torsion, vascular compromise, and irreversible damage.⁶ Therefore, elective repair is recommended promptly after diagnosis to eliminate these risks.

Inguinal hernia is a common condition in pediatric surgery, occurring in approximately 5% of all neonates and nearly 10% of premature newborns.⁷ Traditionally, inguinal hernia repair has been performed using the standard open technique through an inguinal crease incision. However, recent studies have reported several advantages of laparoscopic repair in children, including enhanced visualization, minimal dissection, comparable recurrence rates, reduced risk of metachronous hernia, and improved cosmetic outcomes.⁸ Nevertheless, open repair remains a widely accepted, safe, and cost-effective approach that continues to yield excellent long-term outcomes.

The detection rate of contralateral PPV during LPEC ranges from 20–60%.⁹ Although not all asymptomatic PPVs progress to clinically apparent hernias, previous studies have suggested that persistent PPV may contribute to either metachronous or future hernia development.^10–12 Metachronous hernia appears less frequent after LPEC, partly because contralateral PPV can be addressed simultaneously.¹¹ In female patients, this can be performed with relative technical ease due to the limited structures requiring preservation; therefore, we routinely evaluate and repair the contralateral side in girls undergoing LPEC at our institution. This represents one of the practical advantages of the laparoscopic approach compared with open repair. In contrast, LPEC in boys requires careful preservation of the spermatic vessels and vas deferens, although the procedure can be performed safely with appropriate attention. Details of the sex-specific technique for male patients will be presented in a separate report.

The principal complication of inguinal hernia repair is recurrence. Factors contributing to recurrence include failure to achieve high ligation of the hernia sac at the internal ring,¹³ operative trauma resulting in injury to the inguinal canal floor, insufficient closure of the internal ring, and postoperative hematoma or wound infection.¹⁴ Meta-analyses based on randomized controlled trials, however, have shown that recurrence rates are comparable between laparoscopic and open repairs.^15,16 Careful advancement of the needle in the preperitoneal space and ensuring that only the peritoneum is included in the suture are essential to reduce recurrence risk. If the peritoneum is inadvertently penetrated, the needle should be redirected to the correct plane to avoid exposing the suture intraperitoneally. Non-absorbable sutures such as Ethibond are commonly employed to further reduce the risk of recurrence.

These advantages should be considered in the context of institutional experience, and both open and laparoscopic approaches remain valid and effective options. Technique selection should therefore be guided by institutional expertise, surgeon preference, and patient factors. In our practice, accumulated experience has led LPEC to become the routine technique for pediatric inguinal hernia repair in both boys and girls.

For this procedure, a specialized device known as the Lapa-Her-Closure (short for laparoscopic hernia closure) is utilized in Japan (Figure 1). The device facilitates controlled looping and retrieval of the suture. In female patients, rotation of the needle tip—clockwise on the right and counterclockwise on the left—creates a wider dissection plane while avoiding injury to the external iliac vessels and guiding the needle toward the round ligament. Under optimal conditions, the entire procedure can be completed within approximately 20 minutes from skin incision to closure.

Figure 1. Lapa-Her-Closure (Photograph courtesy of Hakko Medical Co., Ltd., Japan.).

LPEC is typically performed as a day surgery, with most patients being discharged on the same day as the operation. Postoperative wound assessment is conducted at an outpatient clinic approximately one week after surgery. The incision is covered with a waterproof dressing, allowing patients to shower; however, immersion of the wound in water is prohibited until the follow-up visit. If wound healing is satisfactory at the time of evaluation, patients may resume normal daily activities; however, excessive tension or direct stress on the wound should be avoided for approximately one month.

In conclusion, both open and laparoscopic approaches—including LPEC—represent effective and reliable techniques for pediatric inguinal hernia repair. LPEC offers a minimally invasive alternative with specific advantages, while open repair remains an excellent and well-established option.

• 18-gauge needle
• Lapa-Her-Closure (Hakko Co.,Ltd. Medical Device Division, Tokyo, Japan): a ligature carrier consisting of an outer tube (19-G blunt needle) with a cutting edge, through which a rod (17-G needle) slides at its tip with a loop wire that can catch and release suture materials.
• 2-mm port
• 5-mm port
• 5-mm, 30-degree laparoscope
• 2-mm laparoscopic forceps
• 2-0 non-absorbable suture (e.g., Ethibond)
• 3-0 absorbable suture (e.g., Vicryl)
• 5-0 absorbable monofilament (e.g., PDS)
  

Nothing to disclose.

The parents of the patient referred to in this video have given their informed consent for surgery to be filmed and were aware that information and images will be published online.

I would like to express my sincere gratitude to medical engineer Akihito Inoue for his invaluable assistance and cooperation throughout the filming process.

I am also deeply grateful to operating room nurses Yuina Morimoto and Miki Hachitani for their dedicated support during the surgical procedure.