Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) for an Inguinal Hernia with Concomitant Umbilical Hernia Repair in a Pediatric Male

Abstract

This report describes the surgical management of a one-year eight-month-old boy with concurrent right inguinal and umbilical hernias, highlighting both clinical rationale and operative technique. Pediatric inguinal hernias are typically indirect and rarely resolve spontaneously, carrying a persistent risk of incarceration that necessitates surgical repair once diagnosed.

Ultrasonography confirmed a right indirect inguinal hernia with reducible protrusion of the small intestine through a patent processus vaginalis. Although the umbilical hernia showed partial improvement with external compression, the inguinal hernia was unlikely to resolve spontaneously. Therefore, laparoscopic percutaneous extraperitoneal closure (LPEC) was planned, with simultaneous umbilical hernia repair.

LPEC enables high ligation of the hernia sac with minimal dissection and excellent visualization. In male patients, careful technique is required to avoid injury to the spermatic vessels and vas deferens. Tip rotation should be avoided; instead, the needle tip is advanced perpendicularly across these structures at the shortest possible distance to minimize dissection. Gentle manipulation facilitates safe passage, and confirmation that critical structures are not entrapped within the suture loop is essential before ligation. Caudal traction of the testis may further reduce the risk of iatrogenic cryptorchidism.

For umbilical hernia repair, a curved infraumbilical incision is used, which can also serve as a port site for LPEC. Adequate trimming of weakened fascial tissue is essential for preventing recurrence, whereas removal of redundant tissue at the umbilical base is important for achieving a well-defined umbilical depression. Secure fixation of the umbilicus to the fascia is crucial for creating and maintaining this depression, while meticulous hemostasis is required to avoid complications.

In conclusion, simultaneous LPEC and umbilical hernia repair is a safe and effective approach. By combining procedures, surgical burden can be minimized while maintaining reliable outcomes, provided that careful attention is given to key technical considerations.

Keywords

Pediatric surgery; pediatric inguinal hernia; male; LPEC; simultaneous umbilical hernia repair.

Case Overview

Background

In contrast to inguinal hernias in adults, up to 99% of pediatric inguinal hernias are indirect and result from a patent processus vaginalis (PPV).¹ During embryological development, an outpouching of the peritoneum, known as the processus vaginalis, forms along the gubernaculum testis in males. Failure of this structure to obliterate results in persistence as a PPV.²

Definitive repair of pediatric inguinal hernias is achieved 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% in the overall pediatric population, increasing to 11% in preterm infants.³

Focused History of the Patient

This report describes a one-year eight-month-old boy whose parents first noticed a bulging mass at the umbilicus approximately five months before his initial presentation. At that time, a bulging mass was also observed in the right scrotum, which was suspected to represent an inguinal hernia and was subsequently confirmed by ultrasonography demonstrating protrusion of a portion of the small intestine through a PPV.

Although the umbilical hernia was large and dome-shaped, with the hernia sac measuring more than 13 mm in diameter, external compression using a cotton ball was applied to the umbilicus, resulting in near-complete reduction of the bulge. However, spontaneous resolution of the inguinal hernia was considered unlikely. Therefore, laparoscopic percutaneous extraperitoneal closure (LPEC) was scheduled, and simultaneous umbilical hernia repair was also considered, as the hernia sac had decreased in size, but persisted.

Physical Exam

At the initial visit, a large, dome-shaped umbilical bulge was clearly visible, while a right scrotal bulge was apparent in all positions.

Imaging

Although the diagnosis of inguinal hernia is primarily clinical, ultrasonography is routinely used at our institution as a supplementary tool to visualize the herniated contents and to provide diagnostic reassurance in cases with subtle physical findings.⁴

Ultrasonography confirmed a right indirect inguinal hernia, demonstrating protrusion of the greater omentum and small intestine through a PPV, which was reducible with gentle pressure. No contralateral hernia was identified on screening.

Natural History

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 elevated 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 the diagnosis is established.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 uncommon.^3,5

Umbilical hernias are present in approximately 20% of newborns, and up to 90% close spontaneously by 4 years of age.⁶ Therefore, in general, repair of uncomplicated umbilical hernias is recommended between 3 and 5 years of age; however, approximately 30% of patients still undergo repair before 3 years of age.⁷ Umbilical hernia repair performed before 2 years of age has been reported to be associated with higher costs and an increased frequency of postoperative hospitalization and emergency department visits.⁶ On the other hand, umbilical hernia repair, even in children younger than 2 years, may be performed incidentally in conjunction with other surgical procedures. This approach takes into account the potential benefit of preventing rare complications associated with umbilical hernias, as well as reducing the need for multiple exposures to general anesthesia and the associated burden on parents.

Options for Treatment

Surgical repair of inguinal hernia, 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 approach involves a small incision in the groin, dissection of the hernia sac, and high ligation. Open repair remains widely practiced 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 utilizes a laparoscopic camera and a percutaneous needle system to achieve high ligation of the hernia sac. When an umbilical hernia is present concurrently, the umbilical incision can also be used as a port site for LPEC.

Rationale for Treatment

The decision to surgically manage pediatric inguinal hernias is based on two key considerations: spontaneous resolution is unlikely, and there is a persistent risk of incarceration. Incarceration constitutes an acute surgical emergency, as it carries a significant risk of ischemic injury to the herniated contents, particularly the bowel.

Although umbilical hernia repair may not be indicated when considered in isolation, the hernia defect was still present, and a combined approach using LPEC allowed for the simultaneous treatment of both conditions. Therefore, elective repair of both inguinal and umbilical hernias is a reasonable strategy.

Discussion

Inguinal hernia is a common condition in pediatric surgery, occurring in approximately 5% of all neonates and nearly 10% of premature newborns.⁸ Traditionally, inguinal hernia repair has been performed using the standard open technique through an inguinal crease incision. However, recent studies have demonstrated several advantages of laparoscopic repair in children, including enhanced visualization, minimal dissection, comparable recurrence rates, a reduced risk of metachronous hernia, and improved cosmetic outcomes.⁹ In males, an additional advantage has been reported, namely a reduced incidence of testicular ascent or iatrogenic cryptorchidism.^10–12

Although recurrence is the major complication of inguinal hernia repair, several meta-analyses have shown comparable recurrence rates between laparoscopic and open repairs.^10,13,14 Another complication of concern in males is testicular atrophy and iatrogenic cryptorchidism.

The incidence of testicular atrophy is comparable to that of the conventional open approach,¹² although the results tend to favor LPEC. We believe it can be further reduced by careful attention to several technical aspects of LPEC. As described in the previous female case,⁴ a specialized device called the Lapa-Her-Closure (laparoscopic hernia closure) is utilized in Japan for LPEC (Figure 1). Although the same device is used in female patients, the surgical technique differs slightly in male patients. In females, tip rotation is a key step after inserting the device into the preperitoneal space, as this technique allows for wide dissection of the preperitoneal space in a short time. In males, however, rotation should be avoided to prevent injury to the spermatic vessels and the vas deferens, as rotation can easily involve these structures and complicate subsequent steps. Instead, the needle tip should pass perpendicularly across these structures at the shortest possible distance. This approach minimizes dissection between these critical structures and the peritoneum. To achieve such minimal dissection, gentle side-to-side or up-and-down movements of the Lapa-Her-Closure tip are effective. It is also essential to confirm that these structures are not entrapped within the suture loop before ligation. To reduce the risk of recurrence, we use a 2-0 non-absorbable suture for closure of the PPV in both male and female patients.

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

With regard to iatrogenic cryptorchidism, its incidence is significantly lower with LPEC,^10–12 possibly due to reduced dissection, resulting in less torsion during healing and fewer adhesions to surrounding tissues. Caudal traction of the testis during ligation may further help prevent this complication.

Even under optimal conditions, the procedure in males takes slightly longer than in females because of the need for delicate needle manipulation. To maximize the intra-abdominal working space, we routinely evacuate bladder contents immediately before surgery using a Nelaton catheter. Indwelling urinary catheterization is generally unnecessary given the short operative time. Pneumoperitoneum is established at a moderate flow with an insufflation pressure of approximately 8 mmHg. On average, the operative time is approximately 30–40 minutes for unilateral repair and 50–60 minutes for bilateral repair.

In female patients, where fewer anatomical structures require preservation, the procedure is simpler, and simultaneous contralateral repair is routinely performed at our institution.⁴ In contrast, in male patients with a symptomatic unilateral hernia, contralateral closure is performed only when the contralateral opening is comparable to that of the affected side or larger. In general, prophylactic treatment of an asymptomatic contralateral PPV is not routinely performed due to the potential complications described above.

For umbilical hernia repair, unlike LPEC, a curved incision along the lower half of the umbilical ring is used. This incision can also serve as a camera port site for laparoscopic procedures, including LPEC. When closing the fascial defect, adequate trimming of the weak tissue surrounding the umbilical defect until the rectus abdominis muscle fibers are exposed is critical to prevent recurrence. Thinning the subcutaneous tissue beneath the umbilical base allows secure fixation of the umbilicus to the fascia. However, excessive trimming may cause bleeding and postoperative hematoma, potentially leading to wound infection; therefore, meticulous hemostasis is essential. This procedure alone typically requires approximately 60 minutes.

When these two procedures are performed simultaneously, the total operative time can often be reduced to approximately 60 minutes due to overlapping steps.

LPEC, umbilical hernia repair, or the combined approach is typically performed as day surgery, with most patients discharged on the same day. Postoperative wound evaluation is conducted at an outpatient clinic approximately one week after surgery, as described in the female patients.⁴

In conclusion, the combined approach of LPEC and umbilical hernia repair offers the advantage of reducing the need for multiple operations. Although LPEC in males requires careful attention to critical structures such as the spermatic vessels and vas deferens, it remains an effective and reliable technique for pediatric inguinal hernia repair.

Equipment

• 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).
• General instruments for open surgery.

Disclosures

Nothing to disclose.

Statement of Consent

A parent of this patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Acknowledgements

The authors would like to express sincere gratitude to Medical Engineer Akihito Inoue for his invaluable assistance and cooperation throughout the filming process. They are also deeply grateful to Operating Room Nurse Miki Hachitani for her dedicated support during the surgical procedure.