Inguinal hernia repair is one of the most commonly performed surgical procedures in childhood. For many years, the golden standard of treatment of inguinal hernia was high ligation and division of the sac by an open inguinal approach.Citation1 In 1990s, when laparoscopic surgery became more popular among pediatric surgeons, many successful laparoscopic inguinal hernia repairs were reported.Citation2 Many laparoscopic techniques have been described but none become golden standard for inguinal hernia repair in children. In 2004, percutaneous internal ring suturing (PIRS) was first time introduced by Patkowski.Citation3 It involves the percutaneous closure of the internal inguinal ring under the control of a laparoscope placed through the umbilical port. First reports of PIRS technique had been associated with higher rates of ipsilateral recurrence and residual hydrocelesCitation3,Citation4 This had been attributed to several factors such as the inexperience of the surgeons, the use of absorbable suture, the use of a single suture or larger defects. More recent publications report lower recurrence and complications rate.Citation4,Citation5 Recently, published meta-analysis had shown the rate of recurrence of 0.7% which is very similar to open surgery.Citation1,Citation4 An incidence of complications in hands of experienced laparoscopic pediatric surgeon is very low. The most common reported complications are injury of blood vessels, recurrence, hydrocele formation, knot reaction, severe pain, and scrotal swelling.Citation4 An advantage of the PIRS technique is better visualization of the peritoneal cavity, and thus the ability to detect other abnormalities or repair a contralateral open inguinal ring that would be a potential hidden hernia.
Many surgeons doubt whether the PIRS technique has a negative effect on testicular blood perfusion and whether there is any difference compared to conventional open surgery. As the internal ring is not closed with circular suturing as in intra-corporeal laparoscopic techniques, and closed by suspending to the abdominal wall, the potential risks may be impaired testicular blood flow resulting in strangulation of the testicular vessels by percutaneous sutures. An example of one such relevant research was the analysis of PIRS technique on testicular artery blood supply. In this study, measured the resistive index value of the testicular artery preoperatively and at the first postoperative month in children who underwent inguinal hernia repair. They found no significant difference between PIRS technique and conventional open surgery with regard to testicular blood flow.Citation6 Similar findings were reported by Tanriverdi et al. who compared peak systolic velocity, end diastolic velocity, and resistivity index of the intratesticular centripetal and testicular capsular arteries between children who underwent laparoscopic inguinal hernia repair (intracorporeal suturing) with PIRS. They also found no statistically significant differences between two groups and concluded that PIRS is a safe technique for inguinal hernia repair with respect to testicular vascularization.Citation7 Many studies confirmed that testicular blood supply was not affected in different open or laparoscopic approaches of inguinal hernia repair.Citation8–10
This study confirmed that PIRS technique has all advantages of minimally invasive surgery. The cosmesis and the virtual extinction of metachronous contralateral hernia are the major advantages. PIRS is safe and effective technique for inguinal hernia repair in children with excellent long-term results and does not cause damage to testicular blood supply. The PIRS procedure might be considered a gold standard for inguinal hernia operations in children.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
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