What is the indications and procedure for herniotomy with contralateral (opposite side) exploration in pediatric (children's) patients?

From the Guidelines

Herniotomy with contralateral exploration is recommended for pediatric patients undergoing inguinal hernia repair, especially in children under 2 years old. The procedure involves surgically repairing the known hernia on one side while also examining the opposite side for a potential occult hernia.

Indications for the Procedure

The indications for herniotomy with contralateral exploration in pediatric patients include:

• Age: Children under 2 years old are at a higher risk of bilateral hernias and therefore benefit from contralateral exploration 1
• Symptomatic unilateral inguinal hernia: Children with a symptomatic hernia on one side are at risk of having a contralateral hernia, and exploration can help identify and repair any occult hernias 1
• Risk factors: Children with a family history of hernias, premature birth, or other medical conditions that increase the risk of hernias may benefit from contralateral exploration 1

Procedure

The surgical approach typically involves:

1. Making a small incision in the affected groin area
2. Repairing the hernia on the symptomatic side
3. Exploring the contralateral side through the same incision or a separate small incision
4. Repairing any occult hernia found on the opposite side This approach is beneficial because:

• Up to 10% of children may have a clinically undetected contralateral hernia 1
• It prevents the need for a second surgery if a hernia develops on the opposite side later
• The risk of complications from exploration is low compared to the benefits The procedure is usually performed under general anesthesia and can often be done as an outpatient surgery. Recovery time is typically short, with most children returning to normal activities within a week.

Benefits and Risks

While some surgeons debate the necessity of routine contralateral exploration, it remains a common practice, especially in younger children where the risk of bilateral hernias is higher 1. The decision should be discussed with parents, considering factors such as the child's age, risk factors, and surgeon's experience. According to a study published in Pediatrics in 2014, patients 5 years or younger who may need surgical care should be cared for by a pediatric surgeon 1.

Special Considerations

Minimally invasive procedures, such as laparoscopy, can be used for hernia repair in infants and children, and should be performed by a pediatric surgeon trained in these techniques 1. Infants and children with medical conditions that increase operative risk, such as congenital heart disease or preterm birth, who must undergo a common surgical procedure, such as hernia repair, should be cared for by a pediatric surgeon 1.

From the Research

Indications for Herniotomy with Contralateral Exploration

• The procedure is beneficial in bilateral hernia of girls, giant hernia, recurrence following failed open repair, and in hernia associated with undescended testis or ambiguous genitalia 2
• Laparoscopic repair is associated with decreased risk of metachronous hernia, which makes it a viable option for contralateral exploration 3, 4, 5
• The procedure can be used as a routine in the pediatric age group, with benefits including reduced risk of metachronous hernia and improved cosmesis 4, 5

Procedure for Herniotomy with Contralateral Exploration

• Laparoscopic inguinal hernia repair is a technically easier procedure that does not require dissection of the vas deferens and vessels 4
• The procedure involves a three-port laparoscopic technique, which provides superior visualization of the relevant anatomy and allows for assessment and repair of a contralateral hernia 5
• The internal ring can be closed with a 3-0 nonabsorbable suture using either extracorporeal or intracorporeal methods of knotting 4

Benefits of Herniotomy with Contralateral Exploration

• Reduced risk of metachronous hernia 3, 4, 5
• Improved cosmesis 4, 5
• Shorter operative times in bilateral hernia 6
• Potential for lower complication rates 5
• Ability to assess and repair a contralateral hernia, which can prevent future complications 3, 4, 5